AUA Clinical Curriculum 2013

AMERICAN UNIVERSITY OF ANTIGUA

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Clinical Curriculum

During the clinical education in Semesters V through X (year 3 and 4) students continue to develop clinical and communication skills in all areas of patient care under the direction of the medical faculty at teaching hospitals in a patient-centered environment. The clinical education consists of 84 weeks of core and elective rotations. The FAM1/INT1 (6 weeks) preliminary clinical training course is an integral component of Semester V. It focuses on enhancing the skills required to perform physical examinations and to interact with patients, family, and health care providers in a US medical environment. The 44 weeks of CLINICAL CORE ROTATIONS (Internal Medicine – 12 weeks; Surgery – 8 weeks; Family Medicine – 6 weeks; OB/GYN – 6 weeks; Pediatrics – 6 weeks; Psychiatry – 6 weeks) include in-hospital patient care which might be combined with outpatient office experience where permitted by state law, creating a learning environment in which clinical competence can be achieved. In addition students have the opportunity to enhance their medical knowledge and strengthen their clinical skills during the 34 weeks of CLINICAL ELECTIVE ROTATIONS in subspecialties of the core subjects, other medical specialties, and research. In general, the duration of an elective rotation is 4 weeks. The clinical rotations are an integrated educational experience which allow students to develop the knowledge, skills, attitudes and professionalism essential to care for patients effectively, efficiently, and humanely. The faculty’s goal is to facilitate learning, to stimulate curiosity, to promote independent thinking, to encourage compassion, to inspire excellent care, and to equip students with the tools for a lifetime of learning. The acquisition of clinical knowledge during the clinical clerkship is supplemented by clinical core subject specific clinical content provided via the university’s BlackBoard e-learning platform.

At the end of the rotation, the student will be able to demonstrate a basic understanding of:

PATIENT CARE Students must be able to provide, under direct supervision, patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Students are expected to demonstrate basic skills under direct supervision:

• Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families.


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• Gather essential and accurate information about their patients. • Make informed decisions about diagnostic and therapeutic interventions based on

patient information and preferences, up-to-date scientific evidence, and clinical judgment.

• Develop and carry out patient management plans. • Counsel and educate patients and their families. • Use information technology to support patient care decisions and patient education. • Perform competently all medical and invasive procedures considered essential for the

area of practice. • Provide health care services aimed at preventing health problems or maintaining health. • Work with health care professionals, including those from other disciplines, to provide

patient-focused care.

MEDICAL KNOWLEDGE Students must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Students are expected to:

• Demonstrate an investigatory and analytic thinking approach to clinical situations. • Know and apply the basic and clinically supportive sciences which are appropriate to

their discipline.

PRACTICE-BASED LEARNING AND IMPROVEMENT Students must be able to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and suggest improvement of patient care practices. Students are expected to demonstrate basic skills under supervision:

• Analyze practice experience and perform practice-based improvement activities using a systematic methodology.

• Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems.

• Obtain and use information about their own population of patients and the larger population from which their patients are drawn.

• Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.

• Use information technology to manage information, access on-line medical information, and support their own education.


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INTERPERSONAL AND COMMUNICATION SKILLS

Students must be able to demonstrate appropriate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patient’s families, and professional associates. Under direct supervision students are expected to:

• Create and sustain a therapeutic and ethically sound relationship with patients. • Use effective listening skills and elicit and provide information using effective

nonverbal, explanatory, questioning, and writing skills. • Work effectively with others as a member or leader of a health care team or other

professional group.

PROFESSIONALISM Students must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Students are expected to:

• Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development.

• Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practice.

• Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities.

SYSTEMS-BASED PRACTICE

Students must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Under direct supervision students are expected to:

• Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice.

• Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.


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• Practice cost-effective health care and resource allocation that does not compromise quality of care.

• Advocate for quality patient care and assist patients in dealing with system complexities.

• Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.

The following is a list of the objectives and goals for the Core and selected Elective Rotations: INTERNAL MEDICINE – 12 Weeks: Students gain general knowledge of internal medicine, which includes health promotion, disease prevention, diagnosis and treatment of men and women from adulthood through old age, from times of health through all stages of acute and chronic illness. Additionally students develop skills in problem solving, decision making and an attitude of caring driven by humanistic and professional values. This rotation incorporates a consideration of human biology, behavior, and understanding of the epidemiology and pathophysiology of disease and the mechanisms of treatment. Students master clinical skills in interviewing, physical examination, differential diagnosis, diagnostic testing strategies, therapeutic techniques, counseling, and disease prevention. Specific elements of the internal medicine curriculum include:

• General internal medicine: In the healthy adult, the student will develop a working knowledge of:

- routine examinations, vaccinations and laboratory studies - interpretation of routine laboratory tests and x-rays - patient confidentiality issues - health promotion, disease prevention, and screening

• Cardiovascular: The student will be able to diagnose and evaluate:

- chest pain - myocardial infarction and angina - congestive heart failure - valvular heart disease - arrhythmias and the interpretation of EKG findings - differential diagnosis of hypertension and its evaluation - peripheral arterial disease - deep vein thrombosis and its complications


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• Gastrointestinal and liver disease: The student will develop knowledge in: - evaluation of abdominal pain - gastroesophageal reflux disease - peptic ulcer disease and disorders of the stomach - assessment of inflammatory bowel disease - irritable bowel syndrome - acute and chronic diarrhea - colorectal and anal disorders - gastrointestinal bleeding - acute and chronic hepatitis, and other hepatic disorders - cirrhosis - ascites - diseases of the biliary tract and pancreas

• Endocrinology and metabolism: The student will develop knowledge in:

- diabetes mellitus - hyperlipidemia - abnormal weight loss or weight gain - obesity - thyroid and parathyroid disease - adrenal insufficiency and Cushing’s disease - abnormalities of the hypothalamic pituitary axis - osteoporosis

• Hematological disorders and oncological disorders: the student will have a working

knowledge of: - anemia - abnormalities of white blood cell count - increased or decreased platelet count - leukemias and myeloproliferative disorders - multiple myeloma and lymphomas - cancer pathogenesis, evaluation and treatment options of more common cancers

• Pulmonary: The student will be instructed in the differential diagnosis, evaluation and

treatment of pulmonary diseases including: - shortness of breath - asthma - chronic obstructive pulmonary disorders - pulmonary fibrosis - pleural effusion - pulmonary emboli - sleep apnea


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• Infectious disease: The student will assess inpatient evaluation and management of

infectious diseases including: - a general approach to fever - pneumonia - urinary sepsis - bacteremia - HIV disease and other viral diseases - nosocomial infections

• Renal disease: The student will recognize and evaluate elements of:

- acute renal failure - chronic renal failure - dialysis - acid based disorders - electrolyte disorders - disorders of calcium and phosphorous metabolism - management of arterial blood gas findings

• Rheumatology and musculoskeletal disease: The student will learn to assess and

evaluate joint and muscle pain disorders including: - approach to joint pain - septic arthritis - rheumatoid arthritis - osteoarthritis - gout - pseudo gout - systemic lupus erythematosus - connective tissue disease - fibromyalgia - acute and chronic back pain - pain management techniques

• Neurosciences: These include: - altered mental status - headaches - syncope - cerebrovascular accidents - peripheral neuropathy - paralysis


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• Dermatology: These include dermatological diseases: - dermatitis - infectious and fungal skin lesions - cutaneous manifestations of more general systemic disorders - dermatologic malignancy

• Substance abuse: The student will develop a knowledge of:

- alcoholism and substance abuse as it relates to general internal medicine and patient behaviors

- smoking cessation SURGERY – 8 Weeks: Students will gain an appreciation of the specific role of surgeons in the spectrum of medical care. Students should demonstrate an understanding of procedures for surgical admission and the elements of establishing surgical diagnoses. Preoperative evaluation and preparation for an operation will be considered. There should be demonstration of the understanding of immediate postoperative care of the surgical procedure as evidenced by the relevant information described in the brief preoperative note. There should be demonstrable evidence of understanding of immediate postoperative care of the surgical patient, maintenance of the postoperative management of the patient. There should be evidence of the understanding of the activity that should be undertaken on a daily basis in the care of the surgical patient and an understanding of the elements of progress in the postoperative patient including an appreciation of the complications. There should be evidence of an understanding of the legal aspects of the medical record.

• systemic response to injury and metabolic care of the surgical patient • fluid and electrolytes • hemostasis, surgical bleeding, transfusion and nutritional support • shock and physiologic monitoring • burns • surgical infections • wound care • surgical complications • skin and subcutaneous disorders • breast disease • thyroid and parathyroid lesions • adrenal disorders • cardiothoracic disorders • peripheral arterial and venous disorders • esophageal disease • diseases of the stomach and duodenum


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• small intestinal disease including Crohn’s disease and appendiceal disorders • acute abdomen • hepatobiliary disorders • pancreatitis and pancreatic tumor • splenic trauma and splenectomy for hematologic diseases • hernias

Throughout the course of the surgical rotation, the students will function as an integral member of a resident/attending team and will spend a significant period of time in the operating room that will be used as a teaching environment. It is expected that the students will participate actively in the care and follow up of their patients and provide appropriate documentation. During the course of the surgical rotation, they will be taught suture and knot-tying, insertion peripheral intravenous catheters, central lines, naso/gastric tube and airway management. PEDIATRICS – 6 Weeks: The objective of the pediatric rotation is to educate students about issues unique to the neonatal period, childhood, and adolescence. The clerkship uses both the hospital and ambulatory venues to focus on human developmental biology, the role of the family, community, and society on child health. There is a major emphasis on the impact of disease and treatment on the developing individual. During the rotation, the students develop the communication, examination, and problem solving skills that are required to evaluate the health status of a pediatric patient. These skills are directed toward the diagnosis and management of acute and chronic illnesses that affect children and adolescents and attainment of the ability to assess the severity of illness in children. The students will develop an understanding of the physical growth and development from infancy through adolescence including the assessment of motor, language, and social development. They will learn to develop strategy for improving rapport with pediatric patients and their parents and to assess the physical changes that the child undergoes. The students will also develop and understanding of the importance of strategies for health promotion, disease, and accident prevention among pediatric patients.

• Throughout the course of the pediatric rotation, a variety of skills will be developed. These include:

- conducting of a patient/parent interview - the performance of physical examinations in pediatric patients in varying age

groups addressing issues unique to the pediatric patient population - assessing written and verbal communication skills - development of a caring and ethical attitude

• The knowledge achieved will include: - an appreciation of issues of growth and development - health maintenance - nutrition of children and alterations of fluid and electrolyte balance


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- the common complaints that bring pediatric patients to the physician’s attention will be related to the variety of diagnoses responsible for those complaints and to effective therapy of the causative illness

• Pediatric emergencies, issues of the newborn and adolescence will be stressed • Common pediatric complaints and their related diagnoses • Pediatric infections • Pediatric neoplasms • Behavioral problems

- poisonings - accidents and injuries

• Pediatric disorders requiring surgical intervention • Practice-based learning will achieve knowledge about the common pediatric illnesses

OBSTETRICS and GYNECOLOGY – 6 Weeks: During this rotation, students will acquire a set of basic educational and technical skills related to the maintenance of women’s health. They will learn to take an obstetrical and gynecological history and physical with emphasis on the breast, abdomen, and pelvis. Students will develop a basic understanding of the pathophysiology in women as they occur from menarche through the reproductive years and menopause. This will include an appreciation of specific obstetric and gynecologic issues encountered at different stages of a woman’s life. Inpatient obstetrical and gynecological admissions and surgical procedures, as well as ambulatory outpatient clinic or private practice experience, provides the necessary core fundamentals of the rotation. The curriculum will include: Obstetrics

• Routine prenatal care • Intrapartum care – assessment of labor and participation in vaginal and cesarean

deliveries • Routine postpartum care • Obstetrical emergencies • Obstetrical education and counseling

Gynecology • Routine GYN care – including the history, physical and pelvic exam • Assessment of abnormal bleeding and pelvic pain • Diagnosis and treatment – fibroids, ovarian cysts, endometriosis, PID, benign

neoplasms, vaginitis • Family planning and contraception counseling


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• Performance of PAP smear and follow-up of abnormal PAP, including colposcopy

• Breast disease/mammogram • Menopause/hormone replacement • GYN emergencies • Preventive GYN medicine

Subspecialties – Electives available at select sites 1. Perinatology

• High risk prenatal care • Obstetrical ultrasound • High risk obstetrical counseling/education • NST/BPD/fetal monitoring

2. Oncology

• Diagnosis, staging, treatment of GYN malignancies • Chemotherapy • Radiation therapy • Colposcopy – abnormal PAP

3. Reproductive Endocrinology/Infertility

• Management of primary and secondary infertility • Treatment fibroids and endometriosis • Minimally invasive surgery • Assisted reproductive techniques

4. Urogynecology/Pelvic Reconstructive Surgery

• Urinary incontinence – medical and surgical treatment • Sexual dysfunction • Vaginal reconstructive surgery • Treatment of GYN/urologic disorders

PSYCHIATRY – 6 Weeks: The objective of the psychiatric rotation is to prepare the student to recognize, assess, and treat a wide range of mental health problems as they may present throughout the life cycle. Emphasis will be placed on assessment of the patient’s mental status


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and personality traits as they relate to the patient’s health practices, to legal issues such as mental competency, dangerousness, and civil commitment, as well as their relevance to clinical management of other medical conditions. Also, the student should be able to use the interview situation to obtain an in-depth history, to perform a comprehensive mental status examination, and to establish a positive professional doctor patient relationship. This knowledge should be the basis of the student’s ability to make a comprehensive diagnosis of common psychiatric conditions. The student should also acquire knowledge of the various therapeutic modalities including pharmacological, psychotherapeutic, and social interventions, and to be aware of their indications and limitations. By becoming more skilled in assessing the personal strengths and vulnerabilities of the patient’s mental state, the student should become more professional in interviewing in all medical settings. The curriculum will be structured to include:

• Acquisition of skills: in interviewing, taking a psychiatric history, determining the

mental status by examination, and recognizing and assessing the principle psychiatric syndromes.

• Assessing and managing emergencies including suicide, violence, psychosis, substance abuse, grief, and trauma.

• Appreciation of the role of diagnostic testing such as blood levels, EEG, and neuro-imaging.

• Establishing a multi-modal therapy including an appreciation of the mechanism of drug actions and side effects as part of the essentials of psychopharmacology.

• Psycho-social therapy including behavioral therapy, group therapy, and rehabilitation. • Consideration of schizophrenia, bipolar disorder, depression, affective anxiety

disorders, personality disorders, eating disorders, dementia, delirium, substance abuse, somatoform disorders, dissociative disorders, factitious disorders, childhood and adolescence syndromes will be included as well as geriatric psychiatric syndromes.

• Considered personal, physical, and psychological abuse will be defined. • The conducting of a patient/parent interview, the performance of physical examination

in pediatric patients in varying age groups. • Written and verbal communication skills, problem solving skills and the development

of a caring and ethical attitude, and forensic issues will be included. FAMILY MEDICINE – 6 Weeks: The objective of the rotation is to prepare medical students to engage in the delivery of comprehensive care to patients of all ages by addressing the diverse health needs of both individual and the family as a unit. The students will learn how the patients progress through the healthcare delivery system, to develop a holistic approach to the patient. Students should develop an understanding of mechanisms of disease process, inpatient care, referrals, consultations, and general resources.


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The curriculum will stress the importance of medical history, physical examination, laboratory findings in an ambulatory/inpatient setting. It will define mechanisms of determining therapeutic plans for management of illnesses and preventive measures. The physician’s office represents the venue for education for the ambulatory medicine patient (where permitted by state law). The cost effectiveness of the laboratory and radiologic diagnostic studies will be emphasized and the appropriateness of consultation and triage will be stressed. All aspects that focus on a given patient will be considered in the light of that individual representing a member of a family unit and society. Students will be exposed to a broad spectrum of diseases. These include breast exams, dermatologic abnormalities, ophthamalgic and otorhinolaryngologic problems, respiratory and cardiovascular disorders, endocrinological abnormalities including diabetes, thyroid and adreanal disorders, a broad spectrum of gastroenterologic problems, neurological and musculoskeletal problems, psychiatric problems including substance abuse and eating disorders. ELECTIVE ROTATIONS

Students choose from a wide selection of elective rotations at various clinical sites including clerkships in the primary specialties and their various sub-specialties. These are most often provided in clinical settings though students may partake in a limited amount of electives in research settings. A description of some of the more popular clinical electives is listed below; however, there are other areas of clinical electives available. Anesthesiology: Management of patients rendered unconscious or insensitive to pain and stress during surgical, obstetric, and certain other medical procedures. Preoperative evaluation and evaluation of and treatment of patients in specialized care and pain management, cardiopulmonary resuscitation, respiratory care problems, and management of critically ill and or inert patients in special care units. Immunology: Study of allergic and immunological disorders including asthma and other related disorders. It is the application of immunologic theory principle and techniques in the investigation and diagnosis of a broad spectrum of allergic and immunologic diseases. Cardiology: Sub-specialty of internal medicine, provides an educational experience in evaluation and management of a wide variety of patients with acute and chronic cardiovascular conditions including coronary heart disease, congestive heart failure, arrhythmia, acute myocardial infarction, and other acute aschematic syndromes, lipid disorders, hypertension,


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cardiomyopathy, vascular heart disease, pulmonary heart disease, peripheral vascular disease, infectious an inflammatory heart disease, and adult congenital heart disease. Critical Care: Sub-specialty of internal medicine. It is the training in managing critically ill patients and supervising critical care units. Students follow patients throughout patient’s stay in critical care units and monitor subsequent course of patients throughout remainder of their hospitalization. It covers various aspects of critical care. Clinical care medicine is multi-disciplinary and major. Students may obtain clinical experience with critically ill patients including surgical patients, shock trauma patients, neurological, neurosurgical patients, pediatrics, intensive care patients, burn unit patients, dialysis unit, anesthesia service, cardio catherization, and high-risk pregnancy intensive care patients, as well as transplant patients. Dermatology: Clinical and practical experience. Students introduced to patients with diseases of the skin, hair, and mucous membranes as well as the continuum of procedures in allergy and immunology, cryosurgery, dermatologic surgery, derma pathology, clinical pathology, parapsychology, pap testing, photobiology, topical and systemic pharmaco-therapy, and microbiology, including sexually transmitted diseases. Emergency Medicine: Foundation of emergency practice in a clinical setting. Education in the following areas: abdominal congestive intestinal disorders, cardiovascular disorders, coetaneous disorders, endocrine and metabolic and nutritional disorders, head and neck disorders, hematologic disorders, immune system disorders, systemic infectious disorders, musculoskeletal disorders, nervous systems disorders, obstetric and pediatric disorders, psychiatric and behavioral disorders, renal disorders, thoracic respiratory disorders, toxicology and clinical pharmacology, traumatic disorders, and neurogenital and gynecological disorders. Endocrinology, Diabetes and Metabolism: Sub-specialty of internal medicine. It provides clinical experience in the field of endocrinology, diabetes, and metabolism. May include the opportunity to diagnose and manage inpatient and outpatient, adolescent and adult patients of both sexes, representing variable acuity and who have a wide variety of endocrine and metabolic diseases. Gastroenterology: Clinical training in the field including hepatology, clinical nutrition, and gastrointestinal oncology. Experience and expertise in the evaluation of the following disorders: diseases of the esophagus, acid peptic disorders, motor disorders of the gastrointestinal tract, irritable bowel syndrome, disorders of nutrient assimilation, inflammatory bowel disease, gastrointestinal infections, gallstone, alcohol liver diseases, and drug induced hepatic injuries, chronic liver disease, gastrointestinal manifestation of HIV infections, gastrointestinal neoplastic disease, acute and chronic hepatitis. Geriatric Medicine: Sub-specialty of internal medicine provides clinical experience in managing elderly patients with wide variety of medical problems on both an inpatient and


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outpatient basis. Students receive clinical experience in both primary care and consultation of patients in acute, ambulatory, community, and long-term care settings in order to understand the interaction of natural aging and disease, as well as the techniques of assessment, therapy, and management. It is the training in the physiology of aging and the pathophysiology that commonly occur in the older person. Infectious Diseases: Observe and manage adults with a wide variety of infectious disease in both inpatient and ambulatory settings. It provides the opportunities to observe the course of illness and the effects of therapy. Therapeutic administration in hospital, office, and other ambulatory care settings and experience with pediatric infectious diseases is included. Nephrology: Experience in both acute and chronic hemo-dialysis, continuous renal replacement therapy, acute and chronic peritoneal dialysis, and renal biopsy. Students may receive exposure to dialysis and expert corporeal therapies and observe decision making for patients undergoing such therapies. Neurology: Diagnosis and treatment of all categories of disease involving the central, peripheral, autonomic nervous system, including their cover, blood vessels, and all effector tissues, such as muscle. May include both inpatient and outpatient experiences. Oncology: Opportunity to become involved in treatment of both acutely and chronically ill patients and to learn the natural history of cancer as well as the effectiveness of various therapeutic programs. Ophthalmology: Care and treatment of a broad range of ophthamologic diseases. Introduction to major technical and patient care responsibilities in ophthalmic surgery. Preventive Medicine: Study of disease processes as they occur in communities and defined population groups. It provides knowledge of forging stimulation of practices with respect to the community and the individual that will advance health by promoting health-enhancing environments and behavior. Additionally, the student gains experience and knowledge of preventing disease in injury, making possible early diagnosis in treatment, enforcing habilitation and rehabilitation of persons with disabilities. Pulmonary Disease: Observe and participate in the management of inpatients and outpatients with a wide variety of pulmonary diseases. Learn natural history of pulmonary diseases as well as effectiveness of therapeutic treatment. It is an introduction to a broad spectrum of pulmonary disease. Radiology: Diagnostic image-guided therapeutic techniques, including all aspects of radiological diagnosis, nuclear radiology, diagnostic ultrasound, magnetic resonance imaging, computer tomography, interventional procedures, and the use of other forms of radiant energy.


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Rheumatology: Subspecialty of internal medicine. It is an opportunity to participate in the management of inpatients and outpatients with a wide variety of rheumatic and musculoskeletal diseases, and other illnesses with rheumatologic musculoskeletal manifestations. Orthopedic Surgery: Study and prevention of musculoskeletal diseases, disorders, and injuries and their treatment by medical, surgical, and physical methods. Clinical experience includes: inpatient care, preoperative evaluation and post-operative follow up, as well as evaluation in treatment of patients not requiring surgery and alternatives to surgery as modality of treatment for those patients. Pathology: Acquire an understanding of anatomic and or clinical pathology and techniques and methods of those disciplines.

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AUA Clinical Curriculum 2013