Family Medicine Third Year Clerkship
Objectives in the Context of the Six Competencies
I. Medical and Scientific Knowledge:
The MIII student will review cognitive information presented in the didactic conferences; lectures that cover topics common to all primary care and family practice experiences (see lecture schedule). The lecture topics address a variety of issues in family medicine. The lecture content will not be reflected on the written examination. The examination is a standard shelf exam that covers the breadth of family medicine.
In addition, students should becomes familiar with presentations of symptoms and signs and their differential diagnoses of the cases encountered in students’ unique clinical experiences – by diagnoses encountered and by the stages of the disease processes of the diseases suffered by the patients in whom such diseases exist. Many of these disease processes will be illuminated in regular conferences/discussions provided at the rotation sites on which students actively participate. At residency sites this consists of the regular residents’ conferences, occurring at least once weekly. In private offices this will take place on a 1:1 basis along with precepted patient/MIII contact. Review of clinical cases from the New England Journal of Medicine during one of the didactic conferences will direct students to make clinical decisions and arrive at correct diagnoses (I-10)
Both the lecture format and the precepted patient care experience will include applications of basic sciences that bear upon the diseases and patients encountered, which may be relevant and include genetics (I-3), anatomy (I-1), physiology (I-4), epidemiology (I-7) and prevention.
II. Patient Care and Prevention:
1. The MIII should see patients in an outpatient setting in blocks of at least 8 half days per week. These encounters are to be monitored and supervised by faculty of the affiliate site. The standard clinical evaluation form will document the quality of performance. Patient logs entered into myevaluations.com will document achievement of the numbers of patient encounters. The patient logs will be completed by the end of the first three weeks of the clerkship with sign off and remediation recommendations by the preceptor(s). Any remediation must be completed no later than the last day of the six-week clerkship. The student will document at least one patient log from each of the 18 diagnostic categories.
2. The MIII must be observed performing the complete history taking interview and the complete physical examination, and performance noted to be satisfactory. This may occur in one session or in segments throughout the 6-week rotation. Documentation will take place in the form of preceptor signature(s) obtained by the student of the preceptor. (II-2, 3, 4, 5, 7)
3. These patients should represent the broad spectrum of ages and types of problems seen in family practice including health/life-threatening conditions, with the exception being obstetrics. The student will learn clinical decision making, (II-6) modalities of prevention and screening, (II-9) and initial modes of therapy. One patient may account for up to two diagnostic categories. Documentation will occur by a checklist of these following diseases as signed off by preceptor(s) on site. Should the student be unable to obtain any of the diagnostic categories, the student will write a one-page paper on the missing topic(s) to the satisfaction of the clerkship director before a grade is conferred. The student should see professionally cases from each of the following diagnostic categories. (II 3-3)
1. Dermatology (primary condition for visit)
2. Viral URIs and their complications (e.g. sinusitis, bacterial pharyngitis)
3. Lower respiratory conditions (e.g. pneumonitis, asthma, post viral, purulent bronchitis, COPD)
4. Cardiovascular conditions (e.g. coronary artery disease, hypertension, CVA)
5. Upper gastrointestinal (GI) diseases (e.g. GERD, peptic ulcer disease, gastritis)
6. Lower GI diseases (e.g. enteritis, dysentery, irritable bowel syndrome, diverticulitis coli, colorectal cancer or polyps)
7. GU diseases (e.g. cystitis, stress incontinence, hematuria, STD, urolithiasis)
8. Musculoskeletal conditions (e.g. low back or neck strain or herniated disc
9. Migraine or cluster headache
10. Tension headache or HA nos
11. Gynecologic conditions (e.g. vaginitis, dysmenorrhea, menorrhagia, PID)
12. Endocrine diseases (e.g. hypo or hyperthyroidism, diabetes mellitus)
13. Pediatric illnesses, (e.g., asthma, acute otitis media, atopicdermatitis)
14. Pediatric wellness visits
15. Prevention issues including screening (e.g. for cervical, breast, colorectal and prostate cancers, diabetes). (II-8, III-9)
16. Hematology (e.g., anemia, abnormal CBC)
17. Renal diseases (e.g., CKD proteinuria, hematuria)
18. Rheumatologic disorders (e.g., DJD, gout, inflammatory arthritis)
4. The MIII is expected to obtain medical histories and perform examinations without the preceptor present and design diagnostic impressions for each patient with a therapeutic plan; the foregoing information is presented to the preceptor who will check findings as needed and discuss final diagnoses and disposition correcting as required. (II-2, II-3, II-6)
5. The MIII will be introduced to the behavioral aspects of medicine (as discussed in the goals) in outpatient settings. (II-8, III-9)
6. The MIII will be required to perform and write, according to the Introduction to Clinical Medicine course, one source oriented clinical history and physical examination. The patient encounters from which the foregoing are generated must come from interactions between student and patient without the presence of the instructors, though the preceptors will critique the encounters and check findings as he/she sees fit. The H&P will be submitted to the course director using the drop box in D2L. It will be critiqued and approved by the course director for qualification for final grade calculation. The grade for the course will not be conferred until the one H&P and two SOAP notes are approved by the course director. The H&P may be the same as the one monitored. (II-2)
7. The MIII is required to write up and submit, in standard SOAP format two progress notes generated in the actual care of patients encountered by the student under precepted conditions, to the D2L drop box. These will be critiqued and returned or approved by the course director for qualification for final grade calculation (see II-7).
8. The MIII will be taught by preceptors whose emphasis in the foregoing includes professionalism and respect for privacy and dignity of the patients involved. (II-1) This will be evaluated by the site director and documented on the standard clinical evaluation form.
9. In the foregoing experiences students will be required to become familiar with the rationale, technology and ordering format involved in laboratory and other ancillary tests appropriate to the care of patients encountered. (II-5)
10. In these experiences students will be involved in clinical decision-making; preceptors will emphasize shared decision making that includes the contributions of other health care professionals, e.g. pharmacy, nursing, physical and occupational therapy, podiatry, etc., as applicable. (II-8, II-9)
11. In the area of patient care, the student is evaluated by both the Formative (mid-term) & Summative (final) evaluation form supplied to the preceptors.
III. Professionalism and Self-awareness:
Conferences/discussions at rotation sites should include at least one weekly behavioral science focus. This may consist of a patient encounter shared with a behaviorist or precepted by a behaviorist. Ethical dilemmas of medicine are addressed therein. (III-1) Also included are discussions regarding confidentiality, scientific and academic integrity, respect, compassion and altruism (III-4) in relationships with patients, mentors and colleagues.
The foregoing shall include the modeling by mentors and preceptors, advocacy of patients’ interests over those of self (III-5); recognition of one’s limits of knowledge (III-2); and raising of awareness of scientific, financial and organizational conflicts of interest (III-6). This will be evaluated by the site director and documented on the standard clinical evaluation form.
IV. Problem Based Lifelong Learning:
Students are to be given assignments of reading that pertain to their patients and their patients’ diseases and clinical problems and to report on their findings to their peers and mentors. Such interactions reinforce self-criticism (III-9, 10, 12), self-improvement (IV-5), and assimilation of “best practices” in patient care (IV-6). This will be evaluated by the site director and documented on the standard clinical evaluation form. Students will research preventive medicine and outpatient clinical topics and report their findings to faculty at selected conferences. (IV-4, 6) Students will solicit and receive feedback during review of mid-term self-evaluation with preceptor(s). (III-11)
V. Systems Based Inter-professional Practice
Students will appreciate the context within which patients receive care, identify barriers to care and understand the community based and health system resources available. (I-6, 7, V-2, 3, 5, 7) The preceptor or site director will review these areas with the student on a case-by-case basis.
VI. Interpersonal and Communication Skills:
Demonstration of therapeutic, ethically sound, respectful, professional relationships with patients, their families and colleagues is addressed in the orientation to the clerkship before the first of six days of didactic conferences (referred to in I) and stressed during office patient encounters. (VI-1) The student will demonstrate the ability to succinctly present cases to the preceptor(s) including pertinent information. (VI-2, 6) The student will maintain accurate records on patients seen. (VI-3) The student will educate patients and families when appropriate regarding their medical conditions and treatments. (VI-7) This will be evaluated by the site director and documented on the standard clinical evaluation form.