Goal 1: Professionalism (~10%* ) - Demonstrate commitment to excellence, honesty, respect for others, integrity, and altruism in patient care.
Objectives:
- Treat all patients, staff, and colleagues with respect, which includes maintaining a professional demeanor in speech and dress.
- Strive for excellence
- Place the care of your patients above competing interests.
- Learning Activity: Professionalism should imbue all aspects of your performance and cannot really be taught in isolation. However, reflection is a way to help maintain professional behavior. There are many activities in the portfolio that can promote this. Each student will participate in a small group discussion of reflective writings.
- Evaluation: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument. Portfolio advisors will evaluate portfolio submissions and your interactions with them as well (including timeliness, attitude, initiative). How you treat staff, nurses, and all members of the health care team can play a role in this evaluation, though the clerkship does not specifically seek out formal feedback from these individuals.
Goal 2: Patient Care (~25%*) - Evaluate and manage patients hospitalized with acute illness.
Objectives:
- Obtain and record a patient’s history in a logical, organized, and thorough manner.
- Learning activity: Interview, examine, and write an H&P for each new patient assigned to you (even if there is already a note).
- Evaluation: H&Ps are submitted in the portfolio and the portfolio advisor is primarily responsible for evaluating these. The ward attending will give feedback as well, if specifically asked and provided a copy of the H&P. The four best H&Ps are included in the final portfolio for additional evaluation by the Clerkship Director.
- Perform and record a complete physical examination in a logical, organized, and thorough manner for new patients and an appropriately focused physical examination for follow up patients. Be able to recognize normal from abnormal findings and identify the following major abnormalities:
- Be able to identify pulmonary crackles and wheezes
- Be able to identify extra heart sounds, systolic vs. diastolic murmurs, and specifically aortic stenosis and mitral regurgitation
- Be able to recognize and describe stigmata of liver disease
- Learning Activity: Each student should be observed performing a complete physical examination and/or targeted portions to the exam. Harrell Center activities will be arranged to review abnormal heart and lung sounds. Physical finding rounds will be offered to supplement students’ skills.
- Evaluation: House staff and faculty will observe students perform physical examinations in the course of patient care and these observations will inform the summative evaluation. Evaluation forms to use for a formal, observed complete physical examination as well as mini-CEX forms for focused exams are available online to print and give to house staff and faculty to use when examination skills. These or a brief reflection on what was learned may be submitted in the portfolio.
- Obtain and understand important supplemental information, including CBC, Serum chemistries, ABG, coagulation studies, ECG, chest x-ray, and urinalysis.
- Learning activity: Students are provided online learning resources to practice interpreting these tests. Students will be provided an ECG teaching packet supplemented by small group discussion. This data will also be reviewed with the team on rounds and most will be directly discussed in the formal noon “ask the expert” series.
- Evaluation: Students’ understanding of these tests will be assessed in small group discussions on rounds and on the NBME subject exam.
- Formulate and document an assessment that includes the relevant differential diagnoses based on data gathered to guide initial diagnostic evaluation and disease management.
- Learning activity: This will be discussed on daily rounds with the teams and the clinical reasoning process is explicitly taught in the twice weekly “doc in the box” sessions.
- Evaluation: This is assessed by the teams on daily round interactions and review of progress notes. This is also assessed formally in the portfolio with the H&Ps. THIS IS A VERY IMPORTANT PART OF THIS CLERKSHIP.
- Orally present a new patient’s history and physical examination clearly and with appropriate detail.
- Learning activity: This is typically performed with the attending or resident one-on-one and feedback is given at that time, though this can occur as part of rounds.
- Evaluation: Attending and residents who directly observe this will provide formative and summative feedback. A mini-CEX form is available online to enhance this feedback and that may be included in the portfolio.
- Orally present a follow-up patient’s case (including those with more than one problem) in a focused manner, including diagnostic and therapeutic plans.
- Learning activity: This is practiced on daily rounds with the whole team present.
- Evaluation: Attending and residents who directly observe this will provide formative and summative feedback. A mini-CEX form is available online to enhance this feedback and that may be included in the portfolio.
- Write cogent, clear progress notes documenting working diagnosis and status of diagnostic evaluation and therapeutic plans.
- Learning activity: Students practice this by writing daily progress notes on all their patients. These should be on the chart in a timely manner (ideally before noon conference) if feedback is to be given.
- Evaluation: Progress notes are primarily evaluated by the house staff. However, students also have the option of submitting them in the portfolio for additional feedback by the portfolio advisors.
Requirements: Students must complete a minimum of 15 patient write-ups to meet this objective, which is in line with the requirement to work-up an average of two new patients per week. Of these write-ups, at least two-thirds should address a patient presenting with a new problem or exacerbation of an old problem (as opposed to scheduled admissions for chemotherapy, biopsies, or other procedures). Students are strongly encouraged to submit evidence of observed physical exams and oral presentations.
Goal 3: Medical Knowledge (~33%*) - Demonstrate understanding of the clinical presentation, basic physiology, evaluation and management of diseases frequently encountered in an inpatient medicine setting.
Objectives:
1. Review the pathophysiology and be able to recognize and initiate evaluation and management plans for the following disease states/clinical presentations
- Abdominal pain*
- Acute mental status alteration*
- Acute renal failure*
- Acute myocardial infarction/acute coronary syndrome*
- Anemia*
- Arrhythmia
- Back pain
- Chest pain*
- Chronic obstructive lung disease*
- Cough*
- Depression
- Diabetes Mellitus
- Dyslipidemia*
- Dyspepsia/ Peptic ulcer disease*
- Dysuria/urinary tract infections*
- Fever*
- Fluid, Electrolyte, Acid/base disorders*
- Gastrointestinal bleeding*
- Heart failure/valvular heart disease*
- HIV*
- Hypertension*
- Joint pain*
- Liver disease*
- Lower respiratory tract infection*
- Nosocomial infection*
- Common malignancies*
- Sepsis*
- Shortness of breath (acute)*
- Thromboembolic disease*
- Thyroid disorders
- Common geriatric issues*
- Dizziness
- Syncope*
- Headache*
- Pancreatitis*
- Meningitis*
- Asthma
2. Be able to use clinical reasoning to synthesize data into a prioritized differential diagnosis, working diagnosis, and plan.
- Learning activities: *Topics covered in SIMPLE cases that are required. Many topics are also frequently covered in the interactive “doc in the box” teaching sessions. Expert faculty will meet with students for interactive problem solving sessions to reinforce many of the concepts taught in the SIMPLE cases and of course students will actively care for patients with many of these medical problems. The above list also is intended to help guide students’ reading. Students are strongly encouraged to learn about all of their patients’ past medical problems in addition to the acute problems to further enhance their medical knowledge. Biweekly “doc in the box” sessions will explicitly teach the clinical reasoning process using a highly interactive, case-based format.
- Requirements: Students must provide evidence of patient exposure to the core presentations/problems that are in boldface above by using the patient logs. SIMPLE cases may substitute for an actual patient when students do not have the opportunity to care for a patient with one of the required presentations. The following SIMPLE cases are required: 1, 3, 4, 6, 7, 9-12, 16, 18-22, 24-33.
- Assessment methods: National Board of Medical Examiners subject exam (multiple choice) in internal medicine; team evaluations (based on observation) at end of 4 weeks, and assessment of the 4 required patient write-ups.
Goal 4: Practice-based Learning (~15%*) - Develop skills that foster life-long learning habits
Objectives:
- Based on self-assessment and the clerkship objectives, create a set of personal goals for the clerkship and reflect on your progress, modifying as necessary.
- Actively seek feedback and perform reflection and self-assessment routinely.
- Develop a reading/study plan that will work in the busy clinical setting.
- Apply EBM skills learned in 2nd year in an efficient way to patient care
- Learning activities: Students will create an Educational Portfolio with guidance from a faculty advisor, the content of which is partially driven by self-identified learning needs as identified in the goals and formative feedback. The portfolio will include some type of EBM project.
- Requirements: Educational portfolio (with complete requirements as noted elsewhere) that includes written goals, formative feedback, and EBM project.
- Assessment methods: The Clerkship Director and the designated portfolio advisors will review the student’s educational portfolio. Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument. Summative evaluation of the portfolio will be provided in writing by the portfolio advisor.
Goal 5: Human Communications and Interpersonal Skills (~10%*) - Establish effective communication so as to identify and respond to each patient’s emotional needs and their personal desires regarding their medical treatment. Communicate effectively with team members to enhance team dynamics and patient care.
Objectives:
- Speak to patients and their families using language they can understand.
- Be able to convey empathy to patients from a variety of cultures and backgrounds.
- Recognize when patients are confused or require additional emotional support.
- Keep team informed of patients’ progress and communicate with other healthcare members outside the team as needed.
- Learning activities: Students will speak to patients and their families daily on rounds. Students will observe and when appropriate actively participate in more advanced communications with patients and their families such as breaking bad news, obtaining informed consent, obtaining advanced directives, explaining new diagnoses or treatments.
- Assessment methods: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument. Students have the option to have patients and families evaluate their communication skills using a structured questionnaire provided by the clerkship.
Goal 6: Systems-based Practice (~10%*) - Develop an understanding of resources needed by patients and the resources and limitations of the current health care system. Work effectively as part of a team.
Objectives:
- Work as an effective member of the patient care team, demonstrating reliability, initiative, organization, and helpfulness.
- Gain an understanding of interdisciplinary coordination and planning required when transitioning patients from the inpatient to outpatient setting.
- Act as your patients’ advocate.
- Learning activities: Work with house staff and patient care resource managers one-on-one to help recognize and meet patients’ specific needs for interdisciplinary services or other supports both in the hospital and after discharge. Discuss cases with consultants and the non-physician members of the health care team when they are involved. Make post discharge phone calls to follow-up your patients using a checklist that is found in the portfolio and reflect on any implications to patient safety and quality of care.
- Assessment methods: Daily participation on work rounds, progress notes, and discharge planning paperwork will be assessed by the attending physician and house staff and feedback given at that time and in a structured evaluation instrument. Reflection on post discharge follow-ups will be submitted in the educational portfolio assessed by the portfolio advisor and/or clerkship director.
Global Assessment: Formative and Summative Feedback
In addition to the specific assessment methods detailed for each competency, many of which are primarily formative feedback, students are required to meet with each attending physician mid-rotation for global formative feedback using the clerkship evaluation form found on the website under “evaluations”. Summative feedback that assesses performance in all six competencies occurs in a facilitator-directed team evaluation session at the end of each 4 weeks using a structured evaluation instrument with performance-based rating anchors.
*Percentiles in parentheses represent each competency’s approximate contribution towards the final clerkship evaluation. |
