Department of Family & Community Medicine

Enhanced Skills Program: OHTN HIV Residency in Primary Care

STATEMENT OF PURPOSE

The primary purpose of this comprehensive program is to enhance the provision of HIV care to patients in Ontario amongst primary care physicians.

To promote the development of HIV Primary Care Physicians in Ontario, the Department of Family & Community Medicine (DFCM) offers a six (6) month postgraduate training enhanced skills program in HIV/AIDS.

The HIV resident will be trained at a wide variety of clinical sites, encompassing inpatient and ambulatory training where they will participate in the primary care of the HIV patient (henceforth PHA or person living with HIV) and be exposed to a multidisciplinary approach in the management of HIV/AIDS.

This program has been developed as a partnership between the University of Toronto Department of Community & Family Medicine (DFCM) and the Ontario HIV Treatment Network (OHTN www.ohtn.ca).

The specific learning outcomes of this training program are:

1) Become proficient in medical HIV care

The trainee will be able to:

a) Demonstrate knowledge and skills pertaining to the specific health issues that are most relevant to people living with HIV such as (musculoskeletal, cardiovascular, diabetes, early onset of arthritis, mental health issues, etc.).
b) Demonstrate an understanding of the impact of various social determinants of health and well-being on PHAs such as social isolation, housing, unemployment and underemployment, food insecurity, and stigma.
c) Describe the PHA patient’s view of wellness, illness, stigma, resilience and empowerment.
d) Integrate new evidence from clinical, biomedical and social science HIV research into medical care.

2) Become proficient in the communication of HIV health and wellbeing information

The trainee will be able to:

a) Communicate effectively complex and sensitive HIV wellbeing and disease related topics to PHAs
(e.g., use plain and accurate language when describing HPV and HIV or Hep C and HIV to patients)
b) Communicate effectively with other health care providers about PHA health, disease and wellbeing.

3) Show enhanced skills as a Collaborator & Advocate in the HIV health area

The trainee will be able to:

a) Function effectively in a multidisciplinary team to provide high quality care to a diversity of PHAs. These team members would include physicians, nurses, nurse practitioners, clerical staff, therapists, pharmacists, medical specialists and PHAs.
b) Identify and describe feasible ways in which the wellbeing of PHAs can be enhanced (e.g., harm reduction, smoking cessation, stigma reducing approaches to case management, etc.)

4) Proficient at setting up PHA case management plans for incare and outcare PHA patients

The trainee will be able to:

a) Assess, provide and integrate care for a specific group of PHAs (e.g.,substance users) by drafting a plan in
collaboration with the Supervisor/Coordinator of the Residency in HIV Care Program.
b) Demonstrate awareness of the context of patient referrals, and demonstrate increased skills with respect to effective consultation with health care professionals in the patients’ home community by following a self-reporting guideline.
c) Include and ensure appropriate support systems and follow-up for sustained culturally appropriate care
in the case management plan.
d) Demonstrate awareness of community and health resources, and support structures in the AIDS service organizations network in the area and in Ontario by visiting and interviewing with health care promoter/outreach worker, heath program manager/director or other pertinent staff person in at least one major organization (related to the specific PHA group targeted by the resident).

5) Demonstrate enhanced medical education skills

The Trainee will be able to:

a) Teach colleagues, students and residents about one major combined health/social issued faced by PHAs (e.g., depression leading to social isolation and poor health outcomes) in at least one online/in-person
synchronous/asynchronous presentation (this educational opportunity will be provided or found in collaboration with the OHTN and the medical supervisor/coordinator, e.g., the annual online medical preclerkship conference
hosted by the OHTN/Universities Without Walls).

The resident’s educational opportunities include:

1) Outpatient primary care at St. Michael’s Hospital Family Health Team and Maple Leaf Medical Clinic
2) Inpatient management of HIV patients at St. Michael’s Hospital
3) Tertiary HIV Clinic at Positive Care Clinic at St.Michael’s Hospital
4) Inpatient and outpatient HIV Psychiatric care at St. Michael’s Hospital
5) Experience in Palliative care, pain management, end of life care at Casey House Hospice
6) Focus on HIV-related Obstetrics/Gynecology at St. Michael’s Hospital
7) Experience with primary care provider with emphasis on Chronic Pain & Addiction
8) Focus on HIV Pharmacology with an HIV Pharmacist
9) Possibility of elective time in consultation with Program Coordinator
10) Delivering a presentation at the SMH HIV Rounds as well as to the OHTN online preclerkship conference

OBJECTIVES:

In addition to maintaining and fostering all key and enabling competencies in family medicine, as set out by the College of Family Physicians of Canada, the completion of the Enhanced Skills HIV Program will enable acquisition of the following competencies in each of the following domains.

Medical Expert

At the end of the fellowship the resident will be able to:

1. Apply knowledge of the clinical, socio-behavioral, and fundamental biomedical sciences relevant to HIV Medicine.

  • Cite the unique epidemiological, physiological, and social factors that impact HIV incidence and prevalence in members of the LGBT population
  • Demonstrate understanding of the laboratory tests used in the diagnosis of HIV and their respective sensitivities and window periods
  • Perform an HIV point of care test with comprehensive pre-and post-test counselling
  • Perform a focused history and physical exam relevant to a patient presenting with initial HIV infection or for a follow-up visit
  • Accurately interpret results of laboratory investigations, including lymphocyte markers, HIV viral load, and resistance testing
  • Evaluate indications for the initiation of ARV therapy
  • Identify common adverse effects of ARV therapy and demonstrate knowledge of their management
  • Select appropriate ARV medications for the initiation of therapy and for modification of existing therapy
  • Demonstrate knowledge of the current recommendations for health promotion, disease prevention, and preventative care for HIV positive patients (i.e. vaccinations, cancer screening, cardiovascular risk)
  • Identify opportunistic infections and demonstrate knowledge of their prevention/prophylaxis and management
  • Identify malignancies and other chronic complications and comorbid ities related to HIV/AIDS
  • Take a complete sexual health history and screen for pertinent sexually transmitted infections (STIs) and manage and provide counseling for STIs appropriately. Be familiar with public health and legal regulations and requirements
  • Describe the complex relationships between HIV, stigma, psychosocial factors, mental health and addiction
  • Evaluate and manage issues related to chronic pain in the HIV infected patient
  • Be aware of issues related to fertility, gynecological care and obstetrical care

Communicator

At the end of the fellowship the resident will be able to:

  • Exhibit effective communication skills, including verbal and written presentation of patient consultations with the respectful and culturally sensitive use of language
  • Demonstrate sensitivity in determining the constitution of the patient’s family and/or other main social supports, communicate well with the patient’s supports and encourage their involvement in shared decision making when appropriate
  • Sensitively manage the communication of patient information regarding HIV status, and demonstrate understanding of the consent requirements for communication with third party agents
  • Obtain informed consent, providing sufficient information regarding risks and benefits of HIV treatment alternatives

Collaborator

At the end of the fellowship the resident will be able to:

  • Demonstrate an understanding of the roles and specific expertise of infectious disease and other specialists in the care of the HIV positive patient
  • Consult with other professionals in a timely manner, when needed for optimal care of the HIV positive patient
  • Actively involve appropriate members of a patient’s health care team, including allied health workers, in the assessment, planning, and provision of care
  • Collaborate with community agencies, when appropriate, to optimize patient care

Manager

At the end of the fellowship the resident will be able to:

  • Assist a patient in accessing funding for anti-retroviral medications
  • Demonstrate fiscally responsible allocation of government resources in support of HIV positive patients needs

Health Advocate

At the end of the fellowship the resident will be able to:

  • Recognize special needs, impairments, disabilities, and resource limitations of
  • patients
  • Identify and, when appropriate, inform patients of available specialized resources and community supports
  • Advocate for optimal provision of care to the HIV positive patient
  • Advocate for unbiased and sensitive care of HIV positive patients by all healthcare professionals

Scholar

At the end of the fellowship the resident will be able to:

  • Apply lifelong self-directed learning skills to keep up-to-date on advancements in HIV care
  • Appropriately apply evidence-based approaches and knowledge of the current HIV literature to inform clinical decision-making
  • Critically appraise medical information and successfully integrate information from a variety of sources

Professional

At the end of the fellowship the resident will be able to:

  • Identify and appropriately respond to unique ethical issues arising in the care of the HIV positive patient
  • Respect personal/professional boundaries with patients, residents, and faculty
  • Demonstrate insight into his/her limitations and respond appropriately to constructive feedback