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TEMPORARY VISITATION POLICY CHANGE:

Inpatient General Medicine - Blackwell Team

Inpatient General Medicine (Blackwell) Competency-Based Curriculum

Elizabeth Blackwell, M.D.

Elizabeth Blackwell, MD, 1821-1910, was the first woman to graduate from medical school, Geneva Medical College (the precursor to Upstate Medical College), in this country, in 1849. Widely rejected by other schools, her admission candidacy was put to the student body who thought it a joke ("Women doctors! She's probably six feet tall and has a beard!...I wish to speak in favor of the proposition. There has been something lacking here on our beloved campus and in our classroom. Shall we call it beauty, delicacy, refinement, a certain spiritual element which is seldom evident save in the presence of the fairer sex?.. Hear, hear! Bravo!") who sarcastically endorsed her admission, which recommendation then became binding to the college.

Her performance was distinguished, graduating first in her class. She continued her studies with Paget in England and then she opened an infirmary in the slums of New York which later became the New York Infirmary for Women and Children and Women's Medical College. She held the chair of hygiene and then completed her career as professor of gynecology at the London School of Medicine for Children (Lyons AS, Petrucelli RJ. Medicine. An Illustrated History. Abradale Press/Abrams, New York, 1987, pp 569-570; Morantz RM. Feminism, professionalism, and germs: the thought of Mary Putnam Jacobi and Elizabeth Blackwell. Amer Quart 34:459-78, 1982; Tierney J. Elizabeth Blackwell. Med Health RI 82:75, 1999; Gearin LM. The Giant little woman: Dr. Elizabeth Blackwell. J ed Biogr 6:89-96, 1998; Link EP. Elizabeth Blackwell, citizen and humanitarian. Woman Physician 26:451-8, 1971)

Overview

These assignments blend several overlapping educational experiences. First, it offers interns and Junior/Senior residents opportunities to independently care for inpatients with a variety of medical illnesses, under the supervision of full-time hospitalist members. Second, it permits residents to carry out and learn the principles of general medical consultation (within the hospital) also under direct hospitalist supervision. And third, it exposes residents to and educates them about hospitalist medicine.

Residents function under the direct supervision of the hospitalist team admitting and caring for patients. Additional valuable aspects of this assignment include opportunities to independently triage patients in the emergency department and to mimic the roles of attending physicians (especially coordinating care, choosing consultants, and communicating with attending physicians).

Principal Teaching/Learning Activities

-Resident Morning Report (RMR)—
Three mornings each week (Monday, Tuesday, & Thursday) from about 7:45-8:45 AM all Interns, Junior Assistant Residents and Senior Assistant Residents on inpatient floor teams meet with assigned faculty to review patients admitted the previous day. Patients are presented briefly by the intern or resident who admitted them and discussed by the group, facilitated by the attending physician. The focus of the discussion is selected by the presenting resident and may reflect differential diagnosis, specific management issues, or other topics. Faculty members include general internists and subspecialists.

Each Friday from 8:00-9:00 AM the Senior residents meet with assigned specialist attending physicians to review patients admitted the previous day. Selected patients are presented by the residents and further discussion including literature review and didactic teaching is guided by the attending physician.

-Sign-out Rounds (SR) --
Every evening, Monday through Friday, the senior residents (Chief Resident, or his/her designate will be present during the first few months of the academic year), supervise sign-out rounds, which are attended by the out-going day team and incoming ADMITTING team. These may include topical discussions.

-Teaching Attending Rounds (AR) –
Attending rounds format will vary depending on the preference of the attending. There should be discussion of the patients with concurrent teaching.. At the very least this should include bedside rounds on the new patients and others whom the resident/attending feel should be seen by the team. If possible beside rounds should be done on all patients.

-Management Rounds (MR) --
Each day the Attending physician responsible for care of patients on this service will meet with the residents at the mutually agreeable and arranged times, to review specific aspects of patient management. It will be during these occasions that residents are supervised in details of recordkeeping, interaction with other healthcare team members, communication with consultants and family members, and all other aspects of patient management.

-Palliative Care and/or Ethics Rounds (PCR)—
Once each month a voluntary faculty member with special interest and expertise in medical ethics and palliative care conducts palliative care rounds for all residents on inpatient teams. A particular patient or patients is/are selected for presentation. Discussion is directed and facilitated by the faculty member, emphasizing issues pertaining to death and dying, and relevant care and communication skills necessary for residents to develop.

-Noon Conference (NC) --
Each weekday usually from 12 noon to 1 p.m. all residents attend a scheduled conference reviewing core topics in Internal Medicine.

-Journal Club (JC) --
Journal Club is held monthly. Following an annual presentation on the fundamentals of evidence-based medicine, individual residents are assigned a single article to critically review and present, facilitated by a faculty member, and followed by a group discussion.

-Grand Rounds (GR) --
Medical Grand Rounds are held each Wednesday from 8:00 -9:00
a.m. in the Medical Center Auditorium. Formats vary and include invited guests/visiting professor presentations, clinical-pathological conferences, resident presentations, or other didactic, topical, or patient related topics.

-Ambulatory Care Conference --(ACC)
Each month faculty members meet with residents to review individual topics pertaining to ambulatory care medicine. This follows a three-year cyclic schedule of topics, so that our ambulatory care curriculum is presented in its entirety during the time of training for individual residents.

-Back to Basics (BTB)-
Each month the residents choose a key topic in medicine to review in detail form pathophysiolgy to clinical manifestations and management. The topics are chosen by the residents and reviewed by the chief resident prior to discussion Topics generally follow a triennial cycle, covering all subspecialty areas within internal medicine during the time of training of individual residents.

-Turnover Rounds (TR)--
Turnover rounds occur at the end/beginning of each rotation and from 6:30-7:30 a.m. daily. These facilitate transfers of patient care from one resident to another. (Sign in Rounds are a daily version of turnover rounds.)

-EBM conference (EBM)-
Each month the ambulatory resident and intern are expected to investigate a clinical question that they do not have the answer for. Under the guidance of the faculty, they then formulate the question in a scientific format, search the literature for evidence, and develop an answer to the question. This is presented in a conference. Included in the presentation are the question, the search methods, the evidence found, and the conclusions derived.

-Patient Safety and Quality Improvement Conference (PSQI) –
Formerly the Morbidity and Mortality Conference. We now have a monthly conference dedicated to identifying issues that affect patient safety. The issues maybe as varied as knowledge gaps in care for patients with unusual diseases to errors that occur in the course of care. There is a discussion about the residents' role in preventing such issues in the future. If warranted an action plan is made with follow up at subsequent meetings.

-Autopsy Rounds (AuR)
When a death occurs on any of the teaching teams the family is offered the option of performing an autopsy. If an autopsy is performed, we hold a multidisciplinary presentation of the findings that includes medicine, pathology, radiology, surgery, and/or ob/gyn residents and faculty that were involved.

-MKSAP study pan (MKSAP)-
This self directed study plan helps residents stay on track with their didactic reading and helps them evaluate their medical knowledge (strengths and areas of deficit). Residents can help develop individualized study plans to fill in any knowledge gaps and reinforce what they already know. This also helps residents develop skills and habits needed for lifelong learning.

-In-Training Examination (ITE) --
All of our residents must take this examination annually for their own assessment of progress and for edification. When examination results become available, the program director discusses these individually with residents and counsels residents about individualized study programs to facilitate their acquisition of knowledge.

Description of the Rotation

One intern and a junior/senior assistant resident are assigned to these services each month. Residents will admit patients with the hospitalists. Patient care responsibilities will be for patients anywhere in the hospital. Rounds will be made daily with the attending, as described previously.

The resident should arrive each morning sufficiently early to be intimately familiar with his/her patients, certainly well before 7am work rounds. The resident will review graphic sheets, events of the preceding evening or day, diagnostic studies, and be familiar with all new admissions, diagnostic information, and therapeutic interventions. The resident should be prepared to comprehensively present patients to the team on rounds. The resident should also have examined the relevant medical literature and be conversant with patients' problems. Rounds will be made with hospitalists, by arrangement, at mutually convenient times. These will not merely focus on management but will emphasize didactic education and follow the principles and practices of evidence-based medicine. All rounds/activities will recognize residents' many responsibilities, other patients, and therefore will be conducted efficiently and with time constraints and respectful of the binding nature of all ACGME educational and work-hour mandates. Whenever possible there should be continuity of care and educational activities by hospitalists and attending physicians. All patients will be seen and appropriate notes, decisions, and dispositions effected. In addition residents will have teaching attending rounds three or four times a week with the assigned teaching attending physician

A reference list will be appended and key articles provided. This resident should attend morning reports whenever possible. This resident will attend noon conferences, grand rounds, and his/her continuity experiences.

Residents will write all orders and carry out all procedures for these patients.

Goals and Objectives

The principle objective for this month is to complement other resident experiences enabling residents to learn how to function independently for sick hospitalized patients, facilitated by the unique one to one relationship with hospitalists, representing master generalist clinician/educators. As noted, this involves routine admissions, medical consultations, and acute emergent problems.

Residents will gain familiarity, above and beyond other general medical experiences, with diagnosis, differential diagnosis, pathophysiology, management, and preventative aspects of the following topics:

  • medical management of surgical, obstetrics/gynecologic, psychiatric, orthopedic and podiatric and other non-medical patients,
  • those acute medical emergencies noted previously, and
  • those general medical patients and problems encountered in hospitalized patients (as and detailed in the critical care, cardiac care, and inpatient general medicine curricula).
  • emphasis will be placed on evidence-based, cost effective, contemporary management of medical patients and problems.

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

Evaluation of resident competence by faculty attendings (AE)-Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.

  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Principle Educational Goals by Relevant Competency

In the tables below, the principle educational goals for the Faculty Inpatient Service rotation are indicated for each of the six ACGME competencies. The second column of the table indicates the most relevant principle teaching/learning activity for each goal, using the legend below.

* Legend for Learning Activities (See preceding for descriptions)

ACC-Ambulatory Care Conference
AE-Attending Evaluations
AR-Attending Rounds
AuR-Autopsy Rounds
BTB-Back to Basics
DPC-Direct Patient Care
EBM-Evidence Based Medicine
GR-Grand Rounds
ITE-In-Training Exam
JC-Journal Club
MKSAP-Knowledge Self Study Plan
MR-Management Rounds
MS-Multisource Evals
NC-Noon Conference
PCR-Palliative Care/Ethics Rounds
PSQI-Patient Safety/Quality Improvement
RMR-Resident Morning Report
SR-Signout Rounds
TR-Turnover Rounds

1.) Patient Care

Goals and Objectives: PGY-1 Learning Activities* Assessment
Master basic patient interviewing skills DPC, AR, MR AE, AR, TR, MR, MS
Master basic patient exam skills DPC, AR, MR AE, AR, TR, MR,
Master basic psycho-social evaluation skills DPC, AR, , MR, PCR AE, AR, TR, MR,
Define and prioritize patients' medical problems DPC, AR, MR AE, AR, TR, SR, MR,, RMR
Generate and prioritize differential diagnoses DPC, AR, MR AE,, AR, TR, SR, MR, RMR
Develop rational, evidence-based management strategies DPC, AR,PCR, JC, MR AE, AR, TR, PR, MR, RMR
Goals and Objectives: : PGY-2 (in addition to above) Learning Activities* Assessment
Interview patients more skillfully DPC, AR, MR AE, AR, MR, SR, TR
Examine patients more skillfully DPC, AR, MR AE, AR, MR, SR, TR
Evaluate psycho-social issues more skillfully DPC, AR, MR, PCR AE, AR, MR, PCR, TR
Define and prioritize patients' medical problems DPC, AR, MR, RMR AE, AR, MR, RMR, TR
Generate and prioritize differential diagnoses DPC, AR,RMR, MR AE, AR, MR, RMR, TR
Develop rational, evidence-based management strategies DPC, AR, RMR, PCR, JC, MR AE, AR, JC, MR, RMR, TR
Manage a large volume of patients DPC, AR, RMR , MR AE, AR, MR, SR, TR
Develop and display leadership skills and responsibility DPC, AR, RMR, PCR, JC, MR AE, AR, MR, RMR, SR TR
Learn to be team leaders DPC, AR,RMR, JC, MR AE, AR, NC, , MR, SR, TR
Learn to be efficient teachers DPC, AR, ,RMR, JC, MR AE, AR, SR, MR, CMR, TR
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Efficiently and effectively direct the initial evaluation and continued management of patients requiring hospitalization including appropriate discharge planning. DPC, AR, PR, MR AE, AR, MR, SR, TR
Complete obtainment of certification in required Internal Medicine procedures. Supervises junior trainees in these procedures once certified to teach DPC, AR, PR, MR AE, AR, MR, SR, TR
Systematically obtains and reviews all prior/obtainable medical records pertinent to patient care. DPC, AR, PR, MR AE, AR, MR, SR, TR
Understands significance of all diagnostic test results affecting patient care. DPC, AR, PR, MR AE, AR, MR, SR, TR
Clinical judgment – makes informed decisions using risk/benefit analysis based on sound scientific evidence, patient performance after informed consent and consultation with consultants and more senior physicians (attending). DPC, AR, PR, MR, JC AE, AR, MR, SR, TR, JC
Begin to function as independent primary care givers DPC, AR, PR, MR AE, AR, MR, SR, TR

2.) Medical Knowledge

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Read and expand clinically applicable knowledge base of the basic and clinical sciences DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP AE, AR, TR, MKSAP, MR, SR
Access and critically evaluate medical information and scientific evidence relevant to patient care DPC, AR, RMR, AuR, SR, NC, GR, BTB AE, AR, TR, MKSAP, MR, SR
Goals and Objectives: : PGY-2 (in addition to above) Learning Activities* Assessment
Read and expand clinically applicable knowledge base of the internal medicine specialties DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP AE, AR, TR, MKSAP, MR, SR
Access and critically evaluate medical information and scientific evidence relevant to patient care DPC, AR, RMR, JC, MKSAP AE, AR, PR, JC, SR TR
Teach medical students and interns DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP AE, AR, TR, MKSAP, MR, SR
Read relevant articles and literature in journals DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP AE, AR, TR, MKSAP, MR, SR
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Develop medical knowledge about each patient illness so as to be able to make independent decisions based on scientific evidence and patient preference. DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP AE, AR, TR, MKSAP, MR, SR
Demonstrates knowledge by leading discussions on areas of pathophysiology concerning patient care including ongoing management of hospitalized patients. DPC, AR, RMR, JC, MKSAP AE, AR, PR, JC, SR TR
Demonstrates ability to access information from 3 different sources and to synthesize sources into an in-depth understanding. DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP AE, AR, TR, MKSAP, MR, SR
Develop medical knowledge adequate to practice independently DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP AE, AR, TR, MKSAP, MR, SR

3.) Practice-Based Learning and Improvement

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Identify and acknowledge gaps in personal knowledge and skills DPC, AR, PR, MR, MKSAP AE, AR, MR, SR, TR, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills DPC, AR, PR, MR, MKSAP AE, AR, MR, SR, TR, MKSAP
Accepts guidance from more experienced physicians and uses scientific evidence and practice outcomes for practice improvement. DPC, AR, PR, MR AE, AR, MR, SR, TR
Readily acknowledges practice omissions (errors) determined by self or supervisors and takes corrective measures. DPC, AR, PR, MR, PSQI AE, AR, MR, SR, TR, PQSI
Goals and Objectives: : PGY-2 (in addition to above) Learning Activities* Assessment
Develop plans for practice improvement from feedback. DPC, AR, PR, MR, PSQI AE, AR, MR, SR, TR, PQSI
Reduces level/rate of practice omissions from PGY-1 level (errors). DPC, AR, PR, MR, PSQI AE, AR, MR, SR, TR, PQSI
Improves efficiency of patient care (timelines) while maintaining quality and thoroughness. DPC, AR, PR, MR, PSQI AE, AR, MR, SR, TR, PQSI
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Continues to progressively reduce practice omissions/commissions from R-1, R-2 levels. DPC, AR, PR, MR, PSQI AE, AR, MR, SR, TR, PQSI
From medical knowledge and patient care experiences is able to question patient care practices not supported by scientific evidence/evidenced based care. DPC, AR, PR, MR, PSQI, EBM AE, AR, MR, SR, TR, PQSI
Develop PI skills to use in independent practice DPC, AR, PR, MR, PSQI AE, AR, MR, SR, TR, PQSI

4) Interpersonal Skills and Communication

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Communicate effectively with patients and families DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Communicate effectively with physician colleagues at all levels DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Communicate effectively with all non-physician members of the health care team to assure comprehensive and timely care of patients DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Present patient information clearly, in notes and during presentations DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Goals and Objectives: : PGY-2 (in addition to above) Learning Activities* Assessment
Successfully communicate with patients and families in a group meeting DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Supervise, lead, manage and teach more junior housestaff and medical students. DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Present patient information concisely and clearly, verbally and in writing at an advanced level DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Successfully communicate with patients and families that may be considered difficult (angry, anxious, etc) advanced level DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Become fascicle at discussing difficult issues such as end of life care and delivering bad news DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Effectively teach students and junior trainees to improve their communication skills DPC, AR, MR, PCR AE, AR, RMR, SR, MS

5) Professionalism

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues while maintaining confidentially. DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Always act in a moral, honest professional manner, and maintain appropriate relations with patients. DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Respect and defend each patient's autonomy and privacy and always act in the patients' best interest DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Goals and Objectives: : PGY-2 (in addition to above) Learning Activities* Assessment
Maintain a good record of attendance at conferences, completion of assignments, participation in clinical and didactic activities, prompt completion of dictations DPC, AR, MR, PCR, MKSAP AE, AR, RMR, SR, MS
Understand and apply principles of medical ethics toward patients, families, colleagues, and all members of the health care team DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Understand the principles of moral and ethical behavior required of an independent practitioner DPC, AR, MR, PCR AE, AR, RMR, SR, MS
Become familiar with actual or potential conflicts of interest; particularly those involving personal financial gain. DPC, AR, MR, PCR AE, AR, RMR, SR, MS

6) Systems-Based Practice

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Understand and utilize the multidisciplinary resources necessary to care optimally for patients DPC, MR, AR, AuR AE, AR, RMR, SR
Collaborate with other members of the health care team to assure comprehensive patient care DPC, MR, TR, SR, AR AE, AR, RMR, SR,
Use evidence-based, cost-conscious strategies in the care of patients DPC, AR, EBM , JC AE, AR, RMR, SR, EBM, JC
Goals and Objectives: : PGY-2 (in addition to above) Learning Activities* Assessment
Apply evidence-based and cost-conscious strategies toward disease prevention, diagnosis and disease management. DPC, MR, TR, SR, AR AE, AR, RMR, SR,
Develop understanding of the role of non-physician personnel in the care of patients DPC, MR, TR, SR, AR AE, AR, RMR, SR,
Learn to efficient lead a team through management rounds DPC, MR, TR, SR, AR AE, AR, RMR, SR,
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Develop lifelong strategies to optimize care for individual patients as an independent practitioner DPC, MR, TR, SR, AR AE, AR, RMR, SR,

PROCEDURES

Residents will learn, as appropriate to individual patients, the indications and contraindications and the performance of those medical procedures required by the American Board of Internal Medicine and Residency Review Committee (as detailed in the inpatient general medicine curriculum) and perform all procedures on patients under their care.

Reference List

*All residents are expected to read about their patients in an appropriate general medicine text. In addition, a vast variety of print and on-line reference material is available though the library (24-hour access for all residents) and the on-line portal. Because it is frequently updated, extensively referenced, and includes abstracts of reference articles, the program highly recommends UpToDate as an adjunctive information source. MDConsult is also a valuable resource and residents should become familiar with use as a rapid search engine for clinical information

  1. Adams J, Murray R. The general approach to the difficult patient. Emergency Medicine Clinics of North America 1998; 16:689-99.
  2. O'Keefe KP, Sanson TG. Elderly patients with altered mental status. Emergency Medicine Clinics of North America 1998; 4:701-15.
  3. Jouriles NJ. Atypical chest pain. Emergency Medicine Clinics of North America 1998; 16:717-40.
  4. Fuller GF. Falls in the elderly. American Family Physician 2000; 7:2159-68.
  5. Managing falls in older people. Drug and Therapeutic Bulletin 2000; 38:68-72.
  6. Mahoney J. Immobility and falls. Clinics in Geriatric Medicine 1998; 14:699-726.
  7. DS Cheung, M Kharasch Evaluation of the patient with closed head trauma: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:9-23.
  8. Cunningham R, Mikhail M. Management of patients with syncope and cardiac arrhythmias in an emergency department observation unit. Emergency Medicine Clinics of North America 2001; 19:105-21.
  9. Meyer MD, Handler J. Evaluation of the patient with syncope: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:189-201.
  10. Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:203-20.
  11. Smith BJ: Treatment of status epilepticus. Neurology Clinics 1999; 19;347-69.
  12. Michelson E, Hollrah S: Evaluation of the patient with shortness of breath: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:22137.
  13. Pianka JD, Affronti J: Management principles of gastrointestinal bleeding. Primary Care: Clinics in Office Practice 1999; 28:239-61.
  14. Peter DJ, Dougherty JM: Evaluation of the patient with gastrointestinal bleeding: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:23961.