M-III Internal Medicine clerkship

University of South Carolina School of Medicine-2009-2010

Medi D605

Megan Gleaton2 Medical Park • Suite 402

Phone 803.545.5316 • Fax 803.545.5349Megan.Gleaton@uscmed.sc.edu

Table of Contents

Introduction 1Contacts 1

Goals and Expectations of the Internal Medicine Clerkship 2How to Learn on the Internal Medicine Clerkship 3Suggestions for Success 5Ways to Excel on the Internal Medicine Clerkship 7Professionalism 8

Your Internal Medicine Clerkship 10Goals and Objectives 10Attendance Policy 10Call Schedules and Work-hour Rules 11Typical Daily Schedule 11MICU Rotation 12Medical Student Morning Report 13Chairman’s Presentation 13Simulation Workshop 15Formal Didactics 15Nutrition Activity 16Grading and Evaluation 17Formal Clerkship Objectives 19Core Competencies and Patient Encounters 22

Introduction

Welcome to your Internal Medicine clerkship. We are genuinely delighted to have you join us for this short period. On the clerkship, you will likely only get a small glimpse into the world of internal medicine. Nevertheless, through this experience, we expect that you will acquire fundamental skills, reinforce and expand your knowledge, and develop personally and professionally. We hope that this experience drives you to want to learn more and experience more of what internal medicine has to offer. We wish you the most exciting, stimulating, rewarding, and transforming experience possible over the upcoming weeks.

Clerkship Contacts:

Clerkship Directors:Caroline Powell, MD, MSCR caroline.powell@uscmed.sc.edu

803 540 1000 or 545 5317 – office803 954 6652 – pager803 201 9910 – cell803 754 7019 – home

Mary Beth Poston, MD, MSCR marybeth.poston@uscmed.sc.edu803 540 1000 – office803 954 5419 – pager803 479 7567 – cell

Davinder Lally, MD davinder.lally@uscmed.sc.edu803 540 1000 – office803 954 2316 – pager803 920 9540 – cell

Clerkship Coordinator:Megan Gleaton megan.gleaton@uscmed.sc.edu

803 545 5316

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Advice from the Clerkship Directors in Internal Medicine national organization

Goals for the Clerkship

The primary focus of the medicine clerkship is to increase your capacity to function as a caring, increasingly independent, but supervised clinician on an interdisciplinary internal medicine team.

In seeking to achieve the goals of the clerkship, we believe it is important for you to understand what internal medicine is and what qualities characterize the ideal internist. In the broadest sense, internal medicine is medicine for adults. Internal medicine is by far the largest medical specialty; as such, internal medicine constitutes a major part of the overall landscape of medicine. Internists care for a broad spectrum of patients, ranging in age from adolescence to the ever growing elderly population. Practitioners include primary care general internists who care for adult patients who may present with any problem. Internal medicine also includes sub specialists, such as cardiologists, nephrologists, oncologists, critical care physicians, and many others, who focus on the care of patients with specific diseases and disorders. Many subspecialties of internal medicine are heavily procedure-based.

An internist’s practice may be mostly office-based or hospital-based. The internist coordinates the care of the whole patient by working in concert with colleagues, values a strong patient-doctor relationship, and applies the best scientific evidence. The internist is a clinical problem-solver who is able to integrate pathophysiologic, psychosocial, epidemiologic, and “bedside” information to address urgent problems, manage chronic illness, and promote health. Internists frequently participate in research; many teach students and residents.

“An internist is a physician who can embrace complexity yet act with simplicity.” Louis Pangaro, MD, Vice Chair for Educational Programs, Department of Medicine, Uniformed Services University of the Health Sciences.

Basic Professional Expectations of Third-year Clerkship Students

Attend all clerkship activities on time. If you must be absent, get permission in advance. Dress professionally. The way you dress makes a statement about your school,

hospital, and the medical profession; it may influence the way you are perceived by your patients. If you have any question about what constitutes professional dress, consult your clerkship director.

Treat every member of the health care team, the clerkship team, and every patient with respect.

Answer your pager and email in a reasonable time frame. Make sure your handwriting is legible and ensure every note includes your name, role,

and pager. Preserve confidentiality--do not discuss patients in public places and destroy all papers

with patient specific information that are not part of the medical record. Do not look in the chart (paper or electronic) of any patient for whom you and your team are not caring.

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How to Learn Most Effectively on the Internal Medicine Clerkship

Most learning will take place outside of the classroom, through experiences with patients and interactions with your team. While you may be offered a series of lectures, the bulk of your learning needs to be self-directed. It is essential that you read regularly to answer the questions you encounter each day. Take responsibility for your own education. Make sure that through your reading, experiences, and didactics, you meet the goals of the clerkship.

Understand and clarify, if necessary, the expectations your residents, attendings, and course directors have of you.

Keep a list of questions that arise during your day and seek the answers. Be an active participant in your patients’ care. Be the “go-to” person for all your patients.

Each problem or question that arises is an opportunity to learn. Be a team player. Be available to help all other team members, including other

students. Be around-do not expect your team to find you when something important is happening.

Although you may not always recognize it, you are an integral member of the team. Do not underestimate your importance. Knowing where you fit in and fulfilling the part is very important. As a junior member of the team, it is generally best to be malleable and “go with the flow” of your team. However, if you have an important question or concern, it is equally important that you ask the question or express the concern. Your statements will often result in a valuable contribution to the education and work of the team and to patient care.

Try to be observed and solicit feedback on a regular basis, both positive and constructive. Constructive feedback is essential to your growth in your third year.

Learning moments may come when you least expect it. Pay attention at all times, even when the focus is not on you or your patient.

Strive to practice evidence-based medicine. It is our responsibility to bring the best scientific evidence to every clinical decision that is made. Use evidence-based clinical practice guidelines whenever possible and learn from them.

Demonstrate that you are a self-directed learner by reading during the medicine clerkship. Your education will depend on it.

Learn from your patients whenever possible. Read about all of your patients in depth. The goal is to integrate your basic science knowledge and its application to your patient.

Supplement reading about your patients with periodic use of a review book with test questions to ensure you cover core topics and are prepared for examinations of your knowledge.

It is important for you to gain broad knowledge about the spectrum of medical illnesses as it may be impossible for you to see patients with all conditions about which you need to learn during your clerkship. Follow a structured reading program. It is helpful to have an overview textbook of medicine, one which you can read in depth, ideally from cover to cover; over the course of the clerkship (examples include Internal Medicine Essentials for Clerkship Students, Cecil Essentials of Medicine, Paauw’s Internal Medicine Clerkship Guide, First Exposure Internal Medicine: Hospital Medicine). A reference textbook of medicine is recommended for most patient-related reading (Harrison’s Principles of Internal Medicine, Cecil Textbook of Medicine, ACP Medicine).

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Students also need additional resources to read in greater depth; review articles from the literature or electronic resources are good resources to access. You will also want to have access to small texts for rapid reference (on bedside rounds or in the emergency department, for example). The Washington Manual of Medical Therapeutics is invaluable for formulating treatment plans and writing orders. Ferri’s Care of the Medical Patient and The 5 Minute Clinical Consult also serve this function. These books can be purchased for PDAs for slightly more than their print counterparts (www.skyscape.com has many titles). However, they will not be adequate for helping you understand differential diagnosis, pathophysiology, etc. When it comes time to prepare for the clerkship final examination, many students use MKSAP for Students, an excellent resource produced by the American College of Physicians (ACP) and the Clerkship Directors in Internal Medicine that contains questions with detailed explanations that are organized around the core CDIM training problems.

ACP’s Physician Information and Education Resource (PIER) is an electronic resource that provides evidence-based guidance for managing clinical problems. Access to PIER is free for ACP members and membership is free for students. UpToDate is another excellent electronic resource for investigating specific clinical questions. However, these resources will be less valuable for overview reading of larger clinical topics (an overview of congestive heart failure, for instance). Additionally, the Internet provides access to an enormous library of medical information as a rapid reference.

Students should be self-directed learners and share what they have learned with their colleagues. This practice of continuous, ongoing learning will be necessary throughout your career. When you read, consider preparing a single-page summary; be prepared to present this synopsis to your team. You should do at least one topical presentation per four-week rotation. If your attending or resident does not assign you a topic, pick a clinical subject that interests you and is relevant to at least one of the patients on your current team. If you are having trouble choosing a topic, ask for help from your attending or resident. If you have been given a specific topic to research, do not be afraid to ask for guidance. A concise, summative handout is a nice touch.

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Suggestions for Success in the Inpatient Setting

Your job in the inpatient setting is to care meticulously for the limited number of patients you are assigned, while at the same time learning as much as you possibly can. At times, service and learning may be at odds but generally speaking they coexist quite well. It is useful to recognize that the faculty and house officers you work with are attempting to balance competing demands as well.

Actively and enthusiastically participate in rounds. Demonstrate effective organizational skills.

You will learn more, have more fun, contribute more to patient care, and be less stressed if you keep yourself, your schedule, and your patient information organized. It will come as no surprise to you that being a doctor is a very hectic business. There is a lot to remember. Start training yourself to be organized now!

Carry a calendar and mark all conferences and call days right away. Develop a system for keeping patient data and tasks at your fingertips (note cards, fill-

in-the blank templates, PDA). Have information about your patients immediately available (e.g., vital signs, laboratory

data, diagnostic studies, medications).

Additional Suggestions

Communicate effectively with patients and their families. You have the ability to make an important impact on the care and experience of your

patient. You will likely spend more time with your patients than other members of the team. Your patients may see you as their primary provider, in effect, as “their doctor.”

Spend additional time learning about who your patient is—understand their social, economic, personal background, and values.

After diagnostic and therapeutic plans have been formulated with the assistance of your resident and attending, return to the bedside and discuss them with your patients.

Feel free to have personal and emotional discussions with your patients. You will have the ability to comfort your patients during times of anxiety and fear. You will likely benefit from these discussions as much as your patients. Some sensitive discussions, like disclosing very bad news, should be conducted by more senior members of the team, but you can still be available to provide additional information and support to the patient and family once this information has been presented. Discuss with your team and attending.

Show competency with patient care responsibilities. Be fully prepared and on-time for work rounds everyday and have all pertinent data

available. Have a daily plan for each of your patients. Take the lead in talking with your patients during work rounds. Try to be the first one to get the important pieces of information about your patients. Have all notes and orders promptly co-signed. You may want to carry order sheets with

you on rounds. Discuss this strategy with your team.

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With the guidance of your resident, contact and communicate with all consultants. Participate (including just watching) in as many procedures as possible, even if you are

not following the patient. Try to accompany your patient to any diagnostic evaluations that occur during the

hospital stay. Write admission orders on all patients that you admit. (Even if the intern has already

completed this task, it is very instructive to write your own.) Assist your interns with cross-coverage. Learn about the other patients on your team. You should have at least a basic

understanding of what is going on with all the patients on the team. Pitch in and be of assistance to your resident and intern when your other responsibilities

are taken care of. However, you should not do this to a degree that interferes with your self-directed learning.

Integrate fully into the team. Clarify your role on the team. Ask what is expected of you and deliver it. Show your

interest. Offer to help other members of your team with their patient care if you fulfill your other

responsibilities. This cooperation will allow you to make a greater contribution to patient care and give the team more time for teaching. Offer to research topics and contribute educational presentations in teaching conferences.

Ask for guidance in your reading. Bring what you have learned back to the team. Ask questions when you cannot find the answers yourself.

Ask for feedback. Respond to the feedback you receive.

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Top 10 Ways to Excel on the Internal Medicine Clerkship

1. Find out what your residents and preceptors expect of you. Meet and try to exceed their expectations. Follow through on every assigned task.

2. Be actively involved in the care of your patients to the greatest extent possible. Go the extra mile for your patients. You will benefit as much as they will.

3. Go the extra mile for your team. Additional learning will follow. The more you put in, the more you will gain.

4. Read consistently and deeply about the problems your patients face. Raise what you learn in your discussions with your team and in your notes. Educate your team members about what you learn whenever possible.

5. Learn to do excellent presentations as early as possible. This will make you more effective in patient care and gain the confidence of your supervisors to allow you more involvement in patient care.

6. Ask good questions.7. Speak up—share your thoughts in teaching sessions, share your opinions about

your patients’ care, constructively discuss how to improve the education you are receiving and the systems around you.

8. Actively seek feedback and reflect on your experiences.9. Keep your goals focused on the right priorities, in the following order: patient

care, learning, and personal satisfaction. You should always strive to meet all three goals.

10.Always be enthusiastic. Be caring and conscientious and strive to deliver outstanding quality to your patients as you learn as much as you can from every experience.

Be caring and conscientious and strive to deliver outstanding quality to your patients as you learn as much as you can from every experience.

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Professionalism

The development of professionalism is an explicit and important goal of your clerkship. In 2002, the American Board of Internal Medicine Foundation, American College of Physicians Foundation, and the European Federation for Internal Medicine wrote a charter on professionalism that has gained widespread support (see the charter at www.abimfoundation.org). It starts by stating that “professionalism is the basis of medicine’s contract with society.”

The fundamental principles of professionalism are as follows:Principle of primacy of patient welfare.Principle of patient autonomy.Principle of social justice.

The charter’s set of professional responsibilities are as follows:Commitment to professional competence.Commitment to honesty with patients.Commitment to patient confidentiality.Commitment to maintaining appropriate relations with patients.Commitment to improving quality of care.Commitment to improving access to care.Commitment to a just distribution of finite resources.Commitment to scientific knowledge.Commitment to maintaining trust by managing conflicts of interest.Commitment to professional responsibilities.

It is important to note that some of these principles are occasionally at odds with one another, and in these situations it is important to be able to recognize and effectively negotiate these conflicts when they arise. There are a number of ways to grow your level of professionalism over the course of the clerkship.

Do your best to get to know your patients well. Understand who they are and why they have the problems that they have. Treat every patient as you would hope your family member would be treated. As you invest in your patient, they will invest in you, and this will allow you to experience something that you may not have had before – a true therapeutic relationship.

Follow your patients over time; call them after they have left the hospital to find out what happened to them.

Be an advocate for your patient whenever necessary. Discover for yourself what Francis W. Peabody, MD, articulated: “The secret to caring for the patient is caring for the patient.”

Reflect actively on your actions and experiences, on a regular basis. After each interaction, especially those in which you find you are having strong emotions, spend some time considering and analyzing what you have experienced. Write it down. Discuss your thoughts with your peers and advisors.

Be honest to yourself and others. It is honorable to say, “I don’t know.” Be aware of the “hidden curriculum.” This refers to that which is taught outside the

classroom and which may not be the best examples. Think critically about everything that you are taught, no matter the source.

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Work to improve the quality of the system in which you work. Every medical system has weaknesses, gaps, inefficiencies, and processes that allow errors to occur. Be a part of the solution. Consider ways that the system might be improved and pass them along.

Learn from your mistakes. You will make mistakes. We are human, and we can expect no less of ourselves. And, as a learner, you do not yet have all the knowledge and skills to practice independently. Strive to never make the same mistake twice. Share your experiences with your peers, so they can avoid repeating mistakes. Learn as much as you can about ways to prevent making important errors (and there is a growing literature on how to do this), and be willing to adapt your practice to provide the highest quality and safest patient care.

If any problems occur during your clerkship, let your clerkship director know as early as possible

Conclusion

The Internal Medicine clerkship is one of the most important experiences of medical school. Regardless of what specialty training you ultimately pursue, you will unquestionably advance your knowledge and skills on this clerkship.

Ultimately, we will view this as a successful clerkship experience if it makes you a better caregiver, improves your skills, improves your confidence in yourself, helps you to become more professional, and helps you to become more aware of your career preferences. You will be one step further to where you ultimately will be—a skilled, caring, knowledgeable physician in the area of your choice.

You will only have one Internal Medicine clerkship. As much as we may try to make experiences consistent, no two Medicine clerkships are ever the same—from school to school or from student to student. You, your patients, your team, your preceptors and attendings, and your hospital and clinics will ultimately determine the outcome of this experience. This clerkship will shape you, even if in small ways. You will carry your experiences from these weeks with you for the rest of your professional career. We encourage you to do everything that you can to make the very most of this experience. We hope that this handbook has served as a guide of how to do exactly that. We wish you the very best clerkship experience possible. Your clerkship director feels genuinely privileged to accompany and guide you.

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Your Internal Medicine Clerkship

Organization

Your M3 clerkship consists of essentially 8 weeks of inpatient wards. Four weeks will be spent at the VA Medical Center and 4 weeks will be spent at Palmetto Richland Hospital. Some students will have the opportunity to spend 2 weeks in the Medical Intensive Care Unit at Richland. There will be 2 full days of didactic learning, included as part of Orientation Day and on the day of your mid-term exam. Your mid-term exam is a 1 hour test, based on board exam and shelf test style questions. It is for your learning and is not graded. You must complete the exam however as a requirement of the rotation. There will also be one afternoon of clinical topic lectures, and one afternoon will be spent in the simulation center. You are encouraged (but not required) to join your intern, resident, or attending for one or more half day in the resident clinic over the course of the rotation.

Overview of Goals / Learning Objectives:

To develop clinical skills in medical interviewing, physical examination, and medical decision-making through observation and active participation in medical care.

To develop skills in developing differential diagnoses To develop skills in interpreting laboratory data

To understand the pathophysiology of medical illnesses and use this information to direct the evaluation and treatment of patients.

To learn basic differences between inpatient and outpatient medical practice.

To understand the importance of using an evidence-based approach to medical care.

To work as part of a health care team (systems-based practice) in the management of medically complex and socially diverse patients.

Attendance Policy

Attendance is required at all conferences, including morning report, Grand Rounds and noon conference. Pre-rounding on patients in preparation for morning report or working rounds is expected on all days.

If you have previously scheduled commitments, please notify the Clerkship Director and we can try to help you switch your call schedule to get the weekend/day off you need.

If an emergency situation arises (illness, family emergency), please call or page the clerkship director, Dr. Caroline Powell at 954-6652 (pager), 201-9910 (cell). If the clerkship director is not informed of the absence, it will be considered unexcused. The need for making up time missed will be determined on a case by case basis.

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Call Schedules and Work-hour Rules

We follow the USC SOM student work hour rules. At Palmetto Richland, the call schedule is 1 in 4 until 9 pm weekdays, and overnight on Fridays and Saturdays. There has to be a 10-hour break between the time you leave the hospital and return the next morning.

If you are rotating in the MICU, you are required to stay overnight on 2 nights as determined by the MICU attending or fellow.

At the VA Medical Center, the call schedule is 1 in 4 until 9 pm on most nights. There is no night float resident at the VA, so your team will be staying overnight. You are required to stay overnight with your team on 2 nights. When on call overnight, your total number of hours in the hospital may not exceed 30 hours (i.e. you should leave the hospital by noon or after noon conference on your post-call day).

You will get one day off in 7 averaged over a period of 4 weeks. All students have their “switch weekend” off. The last call will be on Tuesday of week 8. You are done with clinical duties after noon conference on Wednesday before OSCE.

Student work hours regulations allow for student attendance at afternoon lectures even on post-call days.

Typical Inpatient Daily Schedule (PHR and VA)

7-8 am Pre-round on your patients8-9 am Morning Report / Chairman’s presentation / Grand Rounds 9-12 pm Work / teaching rounds with the attending12-1pm Noon conference1-4 pm Patient care

Special lectures and presentationsDr. HumphriesGel RoundsResident lecturesAmbulatory experience (optional)

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Medical Intensive Care Rotation (MICU)

Some students will have the opportunity to rotate through the MICU for 2 weeks of their rotation. During your time in the MICU, you will be assigned interesting patients to follow and write daily progress notes just as on the wards.

During the rotation you will take two nights of overnight call. As per the work hours regulations, you will be done with clinical duties after noon conference on your post-call day. You will be required to prepare and present at least one brief topic presentation to the MICU team as part of the rotation. Ideally this will be based on a patient case you have seen during your time in the MICU.

Typical schedule Palmetto Richland MICU:7 am – Check in with Pulmonary fellow in MICU (5th floor PHR) (day 1)

Discuss with the fellow/residents about what time you should arrive during the remainder of your rotation

8-9:30 am – Morning Report / Grand Rounds / Lectures8:45-9:30 – Monday, Wednesday, Friday – Morning lecture

9:30-12 pm – Attending Rounds 12-1 pm – Noon conference1-5 pm – Patient care, special lectures, procedures

Goals / Learning Objectives: To observe the MICU course of patients presenting with acute respiratory

failure, shock, acute GI bleeds, DKA, acute coronary syndromes, and other medical illnesses requiring critical care.

To observe the collection, synthesis, and presentation of complicated patient data in an organized and efficient manner.

To recognize potential clinical diagnoses on the basis of CXR findings. To become familiar with the indications, risks and benefits, overall

technique, and data interpretation for arterial blood gas analysis and pulmonary artery/central venous catheter placement.

To begin to develop skills in managing patients requiring mechanical ventilation.

To begin to define, recognize, and describe the basic pathophysiology of acute hypoxemic respiratory failure, acute ventilatory failure, septic shock, cardiogenic shock, and hypovolemic shock.

To become familiar with the practice of critical care medicine at Palmetto Health Richland and VA Medical Center, and the process by which a multidisciplinary approach to patient care is utilized to optimally manage patients.

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Medical Student Morning Report

In order to offer more directed assistance with oral presentations and clinical reasoning – at the appropriate learning level for students – a separate morning report will be held for medical students only at PHR and for medical students and interns at the VA. There will be 1-2 attendings present to run these sessions.

The following offers an outline and guidelines for the sessions at PHR:

Monday – Large group Morning Report (for all students and residents) – 8:15 – 9:00 AM, PHR basement conference room

Tuesday, Wednesday, Friday – Student Morning Report – 8:15 – 9:00 AM, Basement conference room PHR

2 medical “post-call” students will present cases admitted the previous day

Be prepared to present the case in a concise but comprehensive fashion - history and complete physical exam. This does take practice.

Be prepared to justify any tests, imaging orderedBe prepared to explain the differential diagnosis and the most likely diagnosesBe prepared to briefly explain one learning issue – what did you learn from this case that you would like to share with the other students? What is your “take-home point”?

Discuss each of these points with your team.

Attending faculty will vary. Learning issues will vary by case presented. Each attending will be prepared with a brief teaching topic based on the case or with clinical pearls that arise as the case unfolds.

Thursday – Grand Rounds

At the VA, these sessions are held Monday, Tuesday, Wednesday, and Friday 8-9 am. Students should be prepared to present admissions from the previous day.

Chairman’s Presentations

These are formal case and topic presentations held on select Thursday afternoons during the rotation. As the name suggests, these presentations are made to and evaluated by our Department Chair. They also offer you a chance to teach your peers. This is a requirement of the rotation and all students should attend each session. Formal guidelines developed by the Department Chair are included in this handbook.

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Chairman Presentation GuidelinesM-3 Clerkship Presentation

Goal:Prepare and deliver a formal case presentation with discussion of a key problem of the case (pathophysiology, differential diagnosis, medical ethics, therapeutics, and/or social, make the audience work through the case, stump the attending, etc.)

Objectives: Develop concise, appropriate, rehearsed case presentations Have thorough familiarity with all aspects of case Develop skills of case presentation to carry to all disciplines

Logistics: No more than 8 minutes, 37 seconds to present case Discussion of some aspect of the case of your choosing for 10-15 minutes: NO PowerPoint Radiological studies, electrocardiograms, pathology specimens, etc. as appropriate will always enhance a

presentation Do not read; no or minimal use of notes Stand up before your audience

Evaluation:See form for evaluation of student

Case Presentation“Persistently Polished, Precise Presentation”

It is a presentation of the case not a reporting of the history and physical.

You should demonstrate your knowledge and understanding of medicine in your case presentation.

Good presentations are a result of practice and thoughtful consideration. Good presentations are not reporting of everything you know about the case. Information needs to be integrated and refined before spoke.

DO NOT READ – WE CAN READ! (We Hope)

YOU MUST PRACTICEPresentation should rarely last >5 minutes. Summarize, integrate data.

HPI should cover most of history; ROS pertinent to HPI, etc., almost all information pertinent to case should be presented in 2 or 3 paragraphs. NO specific references to ROS unless identifies a separated unrelated problem covered in an accurate HPI. Social history, past medical history if vital to case and covered in an accurate HPI. DO NOT REPEAT. “As I mentioned,” or “as I said” means you are repeating. SAY IT ONLY ONCE.

Medications are always reported.

Family history is of no significance in an 80 year old with a stroke; don’t include what is not necessary to understand case. THINK BEFORE YOU SPEAK.

Pertinent positives and negatives in history and physical display of your thought process and knowledge of what is or is not important.

Present case as if to communicate the story to a busy, valued consultant who needs to know about the case in detail, but not too much detail. You are calling on your cell phone and it is costing $1.00 a second!

PRACTICE

THINK!

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Simulation Center Workshop

Each student will participate in a Simulation workshop during the rotation. Prior to this workshop, you will be required to view / read the appropriate Procedures Consult tutorials in order to fully understand indications, contraindications, preparation, procedure steps, post-procedure care, and complications. This will ensure your getting maximal benefit from the limited time we have for hands-on activities in the Simulation Center.

Goals / Learning Objectives:

1. To draw venous blood using a model.

2. To place a central venous catheter in the internal jugular vein under ultrasound guidance. To identify important structures on neck ultrasound. To practice skills technical ultrasound skills such as measuring and saving images.

3. To perform a lumbar puncture on a model.

4. To observe and participate in a simulated cardiac / respiratory arrest (“code”).

Formal Didactics

Students will receive formal lectures clinical reasoning, EKG interpretation, Chest Xray interpretation, laboratory interpretation, antibiotics, thyroid / neck ultrasound, congestive heart failure, HIV, acute kidney injury, and anemia. These will be given on orientation day, midterm day, and one afternoon during the rotation so as to not interrupt patient care and resident teaching. A Geriatrics lecture is available on Blackboard and should be studied in preparation for completing the Senior Mentor project due for this rotation. In addition, students will meet with Dr. Humphries for bedside teaching in physical exam skills (especially cardiac exam) once per week – 3:00 pm Tuesdays at PHR (basement conference room) and 1:00 pm Thursdays at VAMC (5 East nurses station). Dr. Brett will also meet with students rotating at PHR on select Fridays after noon conference to discuss heart sounds.

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Nutrition Activities for M3 Clerkship (Part of CSAD)

The practical application of nutrition therapy is important to clinical practice. Medical nutrition therapy can begin with primary intervention and follow through to care at end-stage disease. Each clerkship provides a unique opportunity to use nutrition principles in patient care.

On the CSAD for this clerkship you will find “Participate in a nutritional assessment or other activity”. The clerkship director may provide nutrition lectures or patient assessment opportunities during your rotation. If these hands on opportunities are not available, you may do the online nutrition case study design for this clerkship.

Go to: www.nutrition.med.sc.edu look under “clerkship”1. Click on the name of your current rotation2. Read ONE of the cases. (Remember, you only need to do one per clerkship.) Think

about the practice questions. When you are ready…3. Take the quiz (be sure to type in your name and current clerkship) and submit. Print out

the receipt if you want to have a back-up paper showing that you took the quiz.4. The quiz results will come to my email. They will be graded pass/fail (5/10). Your name

will then be sent to the clerkship director so you can be given credit for participation in the online nutrition activity.

You may call or email me if you have any problems or concerns about the online case studies.

Bon Appetit!

Lynn Thomas, DrPH, RD, CNSDLynn.Thomas@palmettoheath.org434-2466

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Grading Policy & Evaluation Procedures

The following is an overview of the various evaluation methods and procedures.

CSAD observed functions (“Blue card”)8 written H&P’sDaily progress notesWritten admission ordersWritten discharge instructionsTopic presentationsEKG and CXR interpretationObserved H&P – Requires attending observationVenous blood draw Senior mentor fall risk assignmentObserved endoscopic procedureCentral venous line placement under ultrasound-guidanceParticipation in a “code”Nutrition assignment

Subjective assessment using specific measurement scale- 50%*

Appropriate personal and professional conduct- Unprofessional conduct can result in an “incomplete” with need for remediation of all or some portion of the clerkship

Objective Structured Clinical Evaluation (OSCE)- 20%*

National Board of Medical Examiners Subject Exam (shelf test)-30%*

Multiple choice midterm examination

Each student is given the opportunity to evaluate the case presentation series, his or her attending physicians, and the residents with whom he/she worked with. A clerkship evaluation is completed by each student.

*These items comprise the numerical grade. Other items must be completed for successful completion of the course.

The department policy regarding successful completion of this clerkship is that a student must receive a passing grade on all components of evaluation in order to pass the clerkship itself. Failure of the clinical portion of the OSCE will require remediation as Department determined by the Clerkship Directors. Likewise, the time frame in which this remediation occurs will be determined by the course directors and/or Education Committee. As to failure of the shelf exam, retesting will occur in December for periods 1 and 2 and in June for periods 3, 4, and 5. Those failing in period 6 must take the retest in August. If the second attempt at the shelf exam is successful, the final shelf exam score will be an average of the two scores. A second failure of the shelf exam will necessitate repeating the entire clerkship. Until such time that all three components are successfully completed, the student will receive an “Incomplete” for the clerkship but will be permitted to continue on the other clerkships. Likewise, failure to submit CSAD, Patient Encounter Information, and/or the online clerkship evaluation will result in an “Incomplete.”

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In order to complete the rotation, you must turn in the following items: Completed Observed H&P form Completed Senior mentor fall risk assessment Completed CSAD (“blue”) card Completed PEC data – to be entered into New Innovations

You may receive an “Incomplete” if these items are not completed in a timely fashion.

PEC Data

You should enter data on your medical patients into New Innovations. In addition, you should keep a record of the types of medical conditions to which you are exposed and have the opportunity from which to learn. A table has been provided on the back of your CSAD card for collecting this data for review by the clerkship directors. This information is used to ensure that you are seeing the variety of patients and medical conditions needed for an optimal Internal Medicine clerkship learning experience.

Formal Feedback

Over the course of the rotation, you should receive formal feedback from each intern, resident, and attending with whom you work closely. On average, you should receive formal feedback every 2 weeks. You should also be aware that most teachers consider any constructive criticism feedback and will offer suggestions, criticisms, and advice throughout the day as part of feedback on your performance. But don’t be shy about asking for formal feedback. Formal feedback from clerkship directors will be provided on the day of the midterm (or during weeks 4-5) and during week 8 if needed or requested.

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Formal Clerkship Objectives

1. Elicit a through and pertinent patient history, adapting it to the urgency of the time allowed for the interaction. Include the following history:

A.   Chief complaintB.   History of present illness: Describe the significant attributes of a symptom, including location and radiation, intensity, quality, temporal sequence (onset, duration, frequency), alleviating factors, aggravating factors, setting associated symptoms, functional impairment, and patient's interpretation of symptom.C.   Past medical historyD. Health maintenance historyE. Family and social histories, etc.F. Review of Systems

2. Conduct a thorough physical examination. Include the following:A. Describe the four methods of physical examination (inspection, palpation, percussion,

and auscultation), including where and when to use them, their purposes, and the findings that they elicit.

B. Position the patient properly for each part of the physical examination.C. Perform the physical examination for a patient in a logical, organized, respectful, and

through manner, giving attention to the patient’s general appearance, vital signs, and pertinent body regions.

3. Use information gathered from the patient’s history and physical to complete the following:A. Describe physiologic mechanisms that explain key findings in the history and physical. B. Include a discussion of the diagnostic value of the history and physical examination information.C. Formulate a differential diagnosis (problem list) based on the findings from the history and physical examination.D. Formulate a plan of patient evaluation and management, including diagnostic studies and consultations, therapeutic efforts, education of patient, and follow-up plans using an evidence-based approach.

4. Participate in the selection of diagnostic studies with the greatest likelihood of providing useful results at a reasonable cost.5. Interpret laboratory data including basic metabolic panels, liver functions tests, blood counts, arterial blood gases. 6. Assess each problem further by synthesizing and analyzing the data obtained from the diagnostic studies.7. Demonstrate familiarity with basic clinical procedures of internal medicine. 8. Prepare written, comprehensive, and focused new patient workups. Include the following features when clinically appropriate:

A. Provide a history of the present illness accurately, objectively, chronologically, without repetition, omission, or extraneous information.B. Provide comprehensive physical exam information with detail pertinent to the patient’s problem.C. Provide a succinct and unified list of all problems identified in the history and physical examination.D. Provide a differential diagnosis for each problem.E. Provide a diagnosis/treatment plan for each problem.

9. Present orally, clearly, and concisely the plan of problem evaluation and patient management. 10. Participate in discussion with the patient care team (faculty, staff, etc.) during teaching sessions. 11. Communicate positive interpersonal skills with patients and staff. Include the following:

A. Demonstrate respect and appropriate listening skills, including both verbal and nonverbal techniques.B. Demonstrate effective verbal skills, including appropriate use of open- and closed-ended questions, repetition, facilitation, explanation, and interpretation.

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C. Describe how patients’ and physicians’ perceptions, preferences, and actions are affected by cultural and psychosocial factors, including how these factors affect the doctor-patient relationship.

12. Relate successfully to patients, families, and professionals. Include the following:A. Demonstrate appropriate listening skills, including both verbal and nonverbal techniques.B. Demonstrate interest and responsibility in patient care and patients’ needs.

13. Display professional attitudes to learning. Include the following:A. Demonstrate good, consistent work habits.B. Demonstrate inquisitiveness.C. Demonstrate evidence of a desire to learn and improve by reading, studying, and discussing.D.   Demonstrate an ability to respond positively to constructive criticism.

14. Recognize, evaluate, and treat common adult medical problems in both inpatient and outpatient settings. Include the following:

A. Cardiovascular Diseases1. Valvular heart disease2. Congestive heart failure3. Ischemic heart disease4. Pericardial disease5. Peripheral vascular disease6. Arrhythmias

B. Respiratory Diseases1.   COPD/asthma2.   Pulmonary vascular disease3.   ARDS and pulmonary critical care4.   Lung cancer

C. Renal Disease1.   Fluid and electrolyte disorders2.   Hypertension/vascular disorders of kidney3.   Acute renal failure4.   Chronic renal failure

D. Gastrointestinal Disease1.   Neoplasms of the GI tract2.   Pancreatitis3. Peptic Ulcer Disease4. Gastrointestinal bleeding5. Diseases of the Liver and Biliary System

a.    Jaundiceb.    Cirrhosis, complicationsc.    Gallstones

E. Hematology1.   Anemia2.   Leukocyte disorders3.   Hemostasis4.   Coagulation disorders5. Leukemia / lymphoma6. Myelodysplastic syndromes

F. Oncology1.   Oncologic emergencies2. Solid tumors

G.  Metabolic Diseases1.   Principles of nutritional support

  2.   Hyperuricemia and gout3. Lipids

H. Endocrine Diseases

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1. Thyroid disorders2. Diabetes

I. Diseases of Bone and Bone Mineral Metabolism1. Hypercalcemia2. Osteoporosis

J. Musculoskeletal and Connective Tissue Disease1. Rheumatoid arthritis2. SLE3. Osteoarthritis4. Crystal-induced arthropathies5. Infections of joint spaces

K. Infectious Diseases1. Host defenses2. Fever and febrile syndromes3. Bacteremia and septicemia4. Meningitis5. Pneumonia (includes tuberculosis)6. Urinary tract infections7. Immunocompromised host8. Management of/approach to the HIV+ patient9. Cellulitis and osteomyelitis

L. Neurologic Diseases1. Disorders of consciousness and higher brain function, including syncope2. Drug and alcohol abuse, including alcohol withdrawal3. Autonomic dysfunction4. Sensory dysfunction5. Cerebrovascular disease6. Seizure disorders

M. The Aging Patient1. Biology of Aging2. Identify preventive standards for the various adult age groups, to include counseling

and guidance3. Evaluate the effects of illness on the adult and his/her family

N. Cutaneous Disease1. Infectious Disease (Impetigo, HPV, Herpes, Tinea)2. Psoriasis3. Eczema4. Skin Cancer5. Skin breakdown and wound care

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The core competencies and recommended patient encounters for the M3 Internal Medicine Clerkship in Columbia and Greenville are summarized below.

These clerkship goals are based on the national recommendations of the Clerkship Directors in Internal Medicine, as summarized in the “Clerkship Directors’ in Internal Medicine Core Clerkship Curriculum Guide”. This reference may be found at http://www.im.org/CDIM/CurriculumGuide/OnlineCDIMCurriculum.pdf

The Clerkship Directors will ensure that students meet these goals by 1. Communicating these goals to students, supervising residents and faculty physicians2. Monitoring the students’ patient encounter logs every two weeks, including a formal

assessment at the midpoint of the rotation

If any deficiencies are identified, the Clerkship Director will develop a corrective plan with the student and his supervising resident/faculty physicians.

Given the variability in patient admissions, it is likely that students will not personally care for a patient with every recommended training problem. Students may obtain additional training through participation in care of other patients on the teaching services, and by discussion of patients during attending rounds and educational conferences, and through didactic lectures. Students are expected to supplement their training through self-directed learning.

Core CompetenciesStudents are expected to develop basic competence in the following areas:

History Taking and Physical Examination Interpretation of Clinical Information Diagnostic Decision Making Therapeutic Decision Making Case Presentation Basic Procedures

o Required Venous blood draw Interpretation of basic chest radiograph findings Interpretation of basic electrocardiogram findings Observation of endoscopic procedure Participate in cardiac resuscitation using Basic Cardiac Life Support skills

o Recommended Lumbar puncture Microscopic examination of peripheral blood smear Microscopic examination of sputum Gram stain Observation of cardiac catheterization

Basic Nutrition in Clinical Medicine Geriatric Care Coordination of Care and Team Work Communication and Relationships with Patients and Colleagues

o Including cultural competence Self-Directed Learning Bioethics of Care (Ethical Principles in Clinical Medicine) Prevention

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Patient EncountersStudents are encouraged to participate in patient care of patients with the following problems. Required patient encounters are noted in bold font.

Patients Presenting with a Symptom, Sign, or Abnormal Test Resulto Abdominal Paino Altered Mental Statuso Anemiao Back or Knee Paino Chest Paino Cougho Dyspneao Dysuriao Fevero Fluid, Electrolyte, and Acid Base Disorderso Gastrointestinal Bleedingo Upper Respiratory Complaints

Patients Presenting with a Known Conditiono Acute Myocardial Infarctiono Acute Renal Failure and Chronic Kidney Diseaseo Common Cancerso COPD/Obstructive Airways Diseaseo Diabetes Mellituso Dyslipidemiao Coronary Artery Disease/Heart Failureo HIV Infectiono Hypertensiono Liver Diseaseo Major Depressiono Nosocomial Infectionso Obesityo Pneumoniao Smoking Cessationo Substance Abuseo Venous Thromboembolism

Specific Clerkship RequirementsM3 students must see the following conditions/patient types over the course of the 8-week rotation

1. 2 new acute conditions with the emphasis on diagnosis2. 2 new acute conditions with the emphasis on treatment3. 2 chronic conditions4. 2 acute exacerbations of a chronic disease5. 1 patient from a culture not their own6. 1 patient over the age of 65 years

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7. 1 patient with limited access to medical care8. At a minimum, 1 patient with from each of the following categories. Note that students

are encouraged to obtain experience in all recommended patient training problems.a. Congestive heart failure or coronary artery disease (includes HTN)b. Diabetes mellitus (includes diabetic foot ulcer or other complications)c. Shortness of breathd. Fever or infection (includes pneumonia, UTI, sepsis, HIV, cellulitis)e. Musculoskeletal pain (includes monoarthritic pain, tendonitis, bursitis, DJD, RA)f. Anemiag. Abdominal pain or gastrointestinal bleedh. Renal failure (chronic, acute, ESRD, nephrotic syndrome)i. Electrolyte abnormality j. Alcohol, drug or tobacco abuse

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This handbook has been adopted from the Primer to the Internal Medicine Clerkship, 2nd Ed., A Guide Produced by the Clerkship Directors in Internal Medicine.

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