Wayne State UniversityWayne State UniversitySchool of MedicineSchool of Medicine

Department of Internal MedicineDepartment of Internal Medicine

Clerkship Orientation Clerkship Orientation

20052005

The OrganizationThe Organization

Two monthTwo month Inpatient clerkship Inpatient clerkship Single site assignmentSingle site assignment

The Learning ExperienceThe Learning Experience

Students function as an integral Students function as an integral member of the health care team member of the health care team

The learning experience is based The learning experience is based onon– direct patient care direct patient care – clinical teaching clinical teaching – conferences conferences – personal readingpersonal reading

Overall GoalOverall Goal

To help students understand and To help students understand and obtain practical experience in the obtain practical experience in the – recognition recognition – evaluation evaluation – diagnosis and management diagnosis and management

of adult patients with of adult patients with

acute non-surgical illnessesacute non-surgical illnesses

Specific GoalsSpecific Goals

To be able to evaluate and manage To be able to evaluate and manage sick hospitalized patients.sick hospitalized patients.

To develop familiarity with common To develop familiarity with common problems seen by internists problems seen by internists

To understand the role of the To understand the role of the internist in providing care and internist in providing care and coordinating carecoordinating care

Learning Objectives:Learning Objectives:Core ProblemsCore Problems Learning ObjectiveLearning Objective: :

– To develop familiarity with the core problems in To develop familiarity with the core problems in MedicineMedicine

Measurement:Measurement:– This objective may be satisfied by either caring This objective may be satisfied by either caring

for a patient with one of the identified core for a patient with one of the identified core problems orproblems or

– by completing a “Medcase” for that problem. by completing a “Medcase” for that problem. – Students must document patient encounters and Students must document patient encounters and

the corresponding problem on Campus Mobility. the corresponding problem on Campus Mobility. – Medcases profiles must be submitted to clerkship Medcases profiles must be submitted to clerkship

director, all Medcases must be completed XXXX director, all Medcases must be completed XXXX before the conclusion of the rotation.before the conclusion of the rotation.

Core Problems Core Problems

Anemia Anemia 588588 ArrhythmiasArrhythmias

– Atrial fibrillationAtrial fibrillation Arthralgas/arthrits Arthralgas/arthrits 480480 Chest painChest pain

– CAD/ACS CAD/ACS 451451 Common cancers Common cancers

– Breast Breast 265-s265-s– Colon Colon 588588– Lung Lung 501501

Cough and DyspneaCough and Dyspnea– Asthma/COPD Asthma/COPD 416416– Heart Failure Heart Failure 445445– Pneumonia Pneumonia 472472

Diabetes Diabetes 549549

Gastrointestinal DsGastrointestinal Ds– Abdominal pain Abdominal pain 359-s 319-s359-s 319-s– Diarrhea Diarrhea 607607– GI bleeding GI bleeding

Geriatric syndromesGeriatric syndromes– Dementia Dementia 464464– Syncope Syncope 554554

Hepatitis Hepatitis 494494 HIV/AIDS HIV/AIDS 450450 Hypertension Hypertension 773, 397773, 397 Kidney Disease Kidney Disease

– Kidney failure Kidney failure 402402– UTIUTI

Substance AbuseSubstance Abuse Thromboembolism Thromboembolism 489, 460489, 460

Learning Objective:Learning Objective:The H&PThe H&P Learning Objective:Learning Objective:

– To obtain an accurate medical history and To obtain an accurate medical history and perform a thorough physical examination perform a thorough physical examination in an efficient and timely mannerin an efficient and timely manner

MeasurementMeasurement: : – Successful completion and logging of a Successful completion and logging of a

minimum of 12 H&Ps. minimum of 12 H&Ps. – Satisfactory evaluation of one H&P by site Satisfactory evaluation of one H&P by site

directordirector

Learning Objective:Learning Objective:The SOAP NoteThe SOAP Note Learning Objective:Learning Objective:

– To compose an accurate and To compose an accurate and complete SOAP note documenting complete SOAP note documenting the patient’s daily progressthe patient’s daily progress

MeasurementMeasurement: : – Satisfactory evaluation of SOAP note Satisfactory evaluation of SOAP note

by site director by site director – Satisfactory evaluation of SOAP note Satisfactory evaluation of SOAP note

on the end-of-rotation OSCEon the end-of-rotation OSCE

Learning Objective:Learning Objective:Decision Making and the Decision Making and the ddxddx Learning ObjectiveLearning Objective::

– To develop diagnostic decision-making To develop diagnostic decision-making skills that incorporate probability-based skills that incorporate probability-based thinking thinking

Measurement:Measurement:– Successful completion of the assessment Successful completion of the assessment

and plan portion of H&P and SOAP notes and plan portion of H&P and SOAP notes documenting documenting

well ranked differential diagnoses and well ranked differential diagnoses and clinical rationale for the proposed diagnostic clinical rationale for the proposed diagnostic

work-up work-up

Learning Objective:Learning Objective:Interpretation of basic Interpretation of basic labslabs Learning Objective:Learning Objective:

– To accurately interpret the results of To accurately interpret the results of basic tests and properly determine how basic tests and properly determine how the results should influence patient the results should influence patient management including analysis of management including analysis of

acid base and electrolyte disturbancesacid base and electrolyte disturbances renal functionrenal function peripheral smears and complete blood peripheral smears and complete blood

countscounts liver function testsliver function tests basic electrocardiogramsbasic electrocardiograms chest radiographschest radiographs

Learning Objective:Learning Objective:Interpretation of basic Interpretation of basic labslabs Measurement:Measurement:

– Students will complete the Students will complete the “Interpreting Diagnostic Tests” “Interpreting Diagnostic Tests” Examination on Blackboard scoring Examination on Blackboard scoring a minimum of 80% correct.a minimum of 80% correct.

Learning Objective:Learning Objective:TherapyTherapy Learning Objective:Learning Objective:

– To develop therapeutic decision-To develop therapeutic decision-making skills that incorporate making skills that incorporate pathophysiologic reasoning and pathophysiologic reasoning and evidence-based knowledge evidence-based knowledge

Measurement:Measurement:– Satisfactory completion the Satisfactory completion the plan plan

portion of the H&P and SOAP note. portion of the H&P and SOAP note.

Learning Objective:Learning Objective:Good Presentation SkillsGood Presentation Skills Learning Objective:Learning Objective:

– To develop facility with different types of To develop facility with different types of case presentation: written and oral, new case presentation: written and oral, new pt and follow-up pt and follow-up

Measurement:Measurement:– Satisfactory clinical evaluations from Satisfactory clinical evaluations from

their attending and resident physicianstheir attending and resident physicians– Satisfactory completion of the Satisfactory completion of the

presentation component of the end-of-presentation component of the end-of-rotation OSCErotation OSCE

Learning Objective:Learning Objective:R E S P E C TR E S P E C T Learning Objective:Learning Objective:

– To recognize ethical dilemmas and respect To recognize ethical dilemmas and respect different perceptions of health, illness, and different perceptions of health, illness, and health care held by patients of various health care held by patients of various religious, cultural and ethnic backgrounds. religious, cultural and ethnic backgrounds.

Measurement:Measurement:– Students will be evaluated on their Students will be evaluated on their

participation in the small group discussion participation in the small group discussion addressing these issues during the addressing these issues during the reorientation session reorientation session

Learning Objective:Learning Objective:Communication SkillsCommunication Skills Learning Objective:Learning Objective:

– Students will develop proficiency in Students will develop proficiency in communication and interpersonal skills with communication and interpersonal skills with patients and colleagues with attention to patients and colleagues with attention to how diversities of age, gender, race, culture, how diversities of age, gender, race, culture, socioeconomic class, personality, and socioeconomic class, personality, and intellect require sensitivity and flexibility intellect require sensitivity and flexibility

Measurement:Measurement:– Satisfactory completion the end of clerkship Satisfactory completion the end of clerkship

Internal Medicine OSCE Internal Medicine OSCE

Learning Objective:Learning Objective:CollaborationCollaboration Learning Objective:Learning Objective:

– To work in collaboration with other To work in collaboration with other professionals to ensure optimal professionals to ensure optimal patient care. patient care.

Measurement:Measurement:– Students must have two Students must have two

professionalism card completed by professionalism card completed by ancillary personal on the internal ancillary personal on the internal medicine clerkshipmedicine clerkship

Learning Objective:Learning Objective:Transition of careTransition of care Learning Objective:Learning Objective:

– To recognize the importance of ensuring To recognize the importance of ensuring smooth transition of care from acceptance smooth transition of care from acceptance of patients from the Emergency of patients from the Emergency Department, to transfer of patients to Department, to transfer of patients to other services and finally to discharge. other services and finally to discharge.

Measurement: Measurement: – Completion of three discharge progress Completion of three discharge progress

notes one of which must be selected and notes one of which must be selected and turned in for evaluation by the Site Directorturned in for evaluation by the Site Director

Learning Objective:Learning Objective:Recognizing systemsRecognizing systems Learning Objective:Learning Objective:

– to recognize that systems are critical in to recognize that systems are critical in achieving high quality patient care. achieving high quality patient care. Students will make use of systems Students will make use of systems thinking and participate in the process of thinking and participate in the process of assessing current practice. assessing current practice.

Measurement:Measurement:– Completion of a 2-3 paragraph reflective Completion of a 2-3 paragraph reflective

essay outlining the role the health care essay outlining the role the health care system played in the outcome of one system played in the outcome of one assigned patient. This must be turned in assigned patient. This must be turned in to the Site Director prior to completion of to the Site Director prior to completion of the rotation. the rotation.

Learning Objective:Learning Objective:Life long learningLife long learning Learning Objective:

– To develop and practice self-directed life-To develop and practice self-directed life-long learning, including the ability to long learning, including the ability to access and utilize information systems and access and utilize information systems and resources efficiently. resources efficiently.

Measurement:Measurement:– Student will be required to do one formal Student will be required to do one formal

presentation to their team including presentation to their team including literature review, identification of one literature review, identification of one review article and one recent article. This review article and one recent article. This will be evaluated by the attending will be evaluated by the attending physician. physician.

AttestationAttestation

I have received and reviewed the goals and objectives for the I have received and reviewed the goals and objectives for the Junior Junior

Clerkship in Internal Medicine. I am familiar with the expectations Clerkship in Internal Medicine. I am familiar with the expectations andand

understand my role and responsibilities for this clerkship.understand my role and responsibilities for this clerkship.

________________________________________________________ ______________Student signatureStudent signature DateDate________________________________________________________ ______________Attending physician signatureAttending physician signature DateDate________________________________________________________ ______________Resident signatureResident signature DateDate________________________________________________________ ______________Intern signatureIntern signature DateDate________________________________________________________ ______________Intern signatureIntern signature DateDate

ProceduresProcedures

VenipunctureVenipuncture Blood cultureBlood culture Peripheral IV Peripheral IV

catheter insertioncatheter insertion Arterial blood gasArterial blood gas Throat cultureThroat culture Nasogastric tubeNasogastric tube

Digital rectalDigital rectal Urethral Urethral

catheterization catheterization Place and Place and

interpret a interpret a tuberculin skin tuberculin skin test (PPD)test (PPD)

ElectrocardiograElectrocardiogramm

ProceduresProcedures

Indications Indications Contraindications Contraindications RisksRisks BenefitsBenefits Alternatives to a given procedure.Alternatives to a given procedure. What the patient’s experience of What the patient’s experience of

the procedure will be.the procedure will be.

Student ExpectationsStudent Expectations

Attend Year III Internal Medicine Attend Year III Internal Medicine Orientation Orientation

Attend Site Orientation Attend Site Orientation Follow Site Specific schedulesFollow Site Specific schedules Attendance is mandatory; students are Attendance is mandatory; students are

excused for excused for Weekly continuity clerkship session Weekly continuity clerkship session ACLS ACLS WSUSOM recognized holidays--MLK Day, not WSUSOM recognized holidays--MLK Day, not

ValentinesValentines

Daily SchedulesDaily Schedules

Arrive at the hospital early enough to Arrive at the hospital early enough to see and evaluate their patients prior to see and evaluate their patients prior to work rounds work rounds

Attend work rounds and teaching Attend work rounds and teaching rounds with their teamrounds with their team

Attend required conferences Attend required conferences Attend laboratory and x-ray rounds Attend laboratory and x-ray rounds

CallCall

Students will take call with their Students will take call with their assigned team. assigned team.

The nature of call depends on the The nature of call depends on the assigned site; however, call will be no assigned site; however, call will be no more frequent than every fourth night. more frequent than every fourth night.

Students may stay in the hospital all Students may stay in the hospital all night with their team or with the night night with their team or with the night float team as required by their specific float team as required by their specific sites.sites.

Student Duty HoursStudent Duty Hours

Students’ duty hours follow resident Students’ duty hours follow resident duty hours as described under current duty hours as described under current RRC guidelines. RRC guidelines. – May not work more than 80 hours per May not work more than 80 hours per

week week – Must have an average of one day off in Must have an average of one day off in

seven averaged over four weeks. seven averaged over four weeks. – May not spend more than 30 hours in the May not spend more than 30 hours in the

hospital at one time hospital at one time – Must have a minimum of 10 hours Must have a minimum of 10 hours

between duty shifts. between duty shifts.

References and References and Recommended ReadingRecommended Reading Read Dubin the first weekRead Dubin the first week Read about your patients in a Read about your patients in a

standard text book standard text book Do MKSAP 2 questions every nightDo MKSAP 2 questions every night Work through MedcasesWork through Medcases Use a short internal medicine Use a short internal medicine

manual eg Cecil's to read broadlymanual eg Cecil's to read broadly

Evaluation and GradingEvaluation and Grading

Students will be evaluated by each Students will be evaluated by each supervising resident and each attending supervising resident and each attending

Intern evaluations are NOT used for Intern evaluations are NOT used for gradinggrading

Midway through each month of the Midway through each month of the clerkship, students must complete WSU clerkship, students must complete WSU formative evaluation form and review formative evaluation form and review with attending physician. This will set the with attending physician. This will set the stage for receiving meaningful feedback. stage for receiving meaningful feedback.

COMPETENCY DESCRIPTOR(S) BELOW

EXPECTATIONS SATISFACTORY OUTSTANDING

1**. Application of knowledge in the clinical setting Application of knowledge to clinical problem solving, integration of clinical data, development of differential diagnoses

2.** Taking a History Skills in interview techniques, completeness of history, appropriately focused, thorough, organized, accurate, comprehensive

3** Performing a Physical Exam or Mental Status Exam

Technical competency and quality, completeness, follow up, recognition of abnormal and normal findings, focus and level of detail

4.** Communication and relationships with patients and family

Sensitivity to patient’s feelings and/or needs, empathy, compassion, rapport, respect, comfort w/ interactions, putting patients at ease

5.** Professional attributes and responsibilities Attendance, punctuality, commitment, reliability, motivation, conscientiousness, dependability

6. Overall Knowledge Base Breadth and depth of knowledge base at student’s level of training

7. Written and oral case presentations Organization, clarity, use of appropriate terminology, focus of presentation, appropriateness of information

8. Record Keeping (Write-ups, Progress Notes, etc.)

Timeliness of notes, clarity, organization, appropriate inclusion and exclusion of information, accuracy and completeness of information

9. Facility with Technical Skills and Procedures, if applicable

Manual dexterity and competence in performing procedures and/or tests

10. Communication and relationships with health care team

Integration into the team, sensitivity to needs, feelings wishes and/or rights of others, interaction with team members, function within team structure

11. Self-improvement and adaptability Introspection, aware of own limitations, adaptability, receptivity to and acceptance of criticism, motivation, degree of effort, intellectual curiosity

To achieve an overall “Outstanding” clinical evaluation 7 out of 11 items must be in the exceeds expectations category

The ExamThe Exam

NBME subject examinationNBME subject examination 100 questions100 questions 2 hours and 10 minutes2 hours and 10 minutes It is not enough timeIt is not enough time

GradingGrading

ClinicalClinical

GradeGrade

Exam Exam ScoreScore

< 62< 62 (62-(62-WSU Group Mean)WSU Group Mean)

WSU WSU Group MeanGroup Mean

>>1 SD 1 SD WSU Group meanWSU Group mean

OutstandingOutstanding Repeat ExamRepeat Exam PassPass CommendationCommendation HonorsHonors

SatisfactorySatisfactory Repeat ExamRepeat Exam PassPass PassPass CommendationCommendation

UnsatisfactoryUnsatisfactory Repeat Repeat ClerkshipClerkship

Repeat Repeat ClerkshipClerkship

Repeat Repeat ClerkshipClerkship

Repeat Repeat ClerkshipClerkship

Year III Grading FormYear III Grading Form

STUDENT AFFAIRS REVIEW / DATE _______________________________MEDICAL STUDENT REVIEW / DATE ______________________________________

COMPOSITE CLINICAL EVALUATION SUMMARY (N = ____4____)

CLINICAL COMPETENCY DESCRIPTOR(S) FAILS TO MEET COURSE EXPECTATIONS

MEETS COURSE EXPECTATIONS

EXCEEDS COURSE EXPECTATIONS

1.** Application of knowledge in the clinical setting

Application of knowledge to clinical problem solving, integration of clinical data, development of differential diagnoses

2.** Taking a History Skills in interview techniques, completeness of history, appropriately focused, thorough, organized, accurate, comprehensive

3.** Performing a Physical Exam or Mental Status Exam

Technical competency and quality, completeness, follow up, recognition of abnormal and normal findings, focus and level of detail

4. ** Communication and relationships with patients and family

Sensitivity to patient’s feelings and/or needs, empathy, compassion, rapport, respect, comfort w/ interactions, putting patients at ease

5. ** Professional attributes and responsibilities

Attendance, punctuality, commitment, reliability, motivation, conscientiousness, dependability

6.Overall Knowledge Base Breadth and depth of knowledge base at student’s level of training

7. Written and oral case presentations

Organization, clarity, use of appropriate terminology, focus of presentation, appropriateness of information

8. Record Keeping (Write-ups, Progress Notes, etc.)

Timeliness of notes, clarity, organization, appropriate inclusion and exclusion of information, accuracy and completeness of information

9. Facility with Technical Skills and Procedures

Manual dexterity and competence in performing procedures and/or tests

10. Communication and relationships with health care team

Integration into the team, sensitivity to needs, feelings wishes and/or rights of others, interaction with team members, function within team structure

11. Self-improvement and adaptability

Introspection, aware of own limitations, adaptability, receptivity to and acceptance of criticism, motivation, degree of effort, intellectual curiosity

SUMMARY OF CLERKSHIP GRADE COMPONENTS FINAL CLINICAL EVALUATION

“Exceeds” evaluations for competencies 1-5 (identified with **) and “Exceeds” evaluations for at least three (3) other competencies are minimal criteria for an Outstanding Final Clinical Evaluation.

UNSATISFACTORY

SATISFACTORY

OUTSTANDING

WRITTEN EXAM SCORE____________

YOUR GROUP MEAN _____________ SD __________

MINIMUM WRITTEN EXAM PASSING SCORE ____62________

MINIMUM WRITTEN EXAM OUTSTANDING SCORE

UNSATISFACTORY

SATISFACTORY

OUTSTANDING

OTHER ASSESSMENT (SPECIFY)

UNSATISFACTORY

SATISFACTORY

OUTSTANDING

FINAL COURSE GRADE INCOMPLETE HOLD PENDING REASON___________________________________

UNSATISFACTORY

SATISFACTORY

HONORS

Grade AppealsGrade Appeals

All appeals must be made in writingAll appeals must be made in writing Appeals will be presented to the Internal Appeals will be presented to the Internal

Medicine Medical Education Committee Medicine Medical Education Committee which is composed of Year III site directors. which is composed of Year III site directors.

At no time may students appeal their grade At no time may students appeal their grade directly their resident or attending directly their resident or attending physicians or the site director. physicians or the site director.

The IM MEC will meet and make a The IM MEC will meet and make a determination regarding the student’s determination regarding the student’s appeal.appeal.

Student may appeal the IM MEC finding to Student may appeal the IM MEC finding to the Year III Clerkship Grading Committeethe Year III Clerkship Grading Committee

ChecklistChecklist

Turn in signed attestationTurn in signed attestation Complete 12 work-ups12 work-ups Submit H&P, follow-up Submit H&P, follow-up

SOAP note and discharge SOAP note and discharge notenote

Give formal presentation Give formal presentation with lit search and with lit search and articlesarticles

Complete reflective essayComplete reflective essay Complete WSU mid-Complete WSU mid-

rotation form, review with rotation form, review with attending attending

Complete OSCEComplete OSCE Complete Blackboard lab Complete Blackboard lab

interpretation examinterpretation exam Complete clinical rotationComplete clinical rotation Log all cases and Log all cases and

procedures on PDAprocedures on PDA Submit Medcase Submit Medcase

transcripttranscript Pass shelf examPass shelf exam Complete clerkship Complete clerkship

evaluation on PDA evaluation on PDA