Fourth Year

2010-2011 Course Syllabus

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Faculty Members Participating in the Course Delivery

Jonathan Appelbaum, M. D., Education Director for Advanced Internal Medicine

Clerkship Faculty from each regional campus

Cynthia Powell, M. D., Clerkship Director, Orlando
Robert Anderson, M. D., Clerkship Director, Pensacola
Kathleen Kennedy, M. D., Clerkship Director, Sarasota
Raymond Shashaty, M.D., Clerkship Director, Tallahassee
Vinayak Purandare, M.D., Clerkship Director, Daytona Beach
William Hood, M.D., Clerkship Director, Ft. Pierce
Rudolf Hehn, MD, site director, Thomasville
Steven Spence, MD, site director, Rural Tract

Clerkship Goals and Objectives

The Advanced Internal Medicine Clerkship (Medicine Subinternship) is designed to allow students the opportunity to participate in the management of patients with common clinical presentations encountered in the practice of hospital based internal medicine. Each student will have the opportunity to experience a broad range of illness severity ranging from acute care upon presentation to the emergency department to life threatening processes in the intensive care unit. Students will also have the opportunity to improve their basic clinical skills, learn new inpatient procedures and examination techniques, and assess the effectiveness of their clinical interventions. The student will have increasing responsibility for the care of patients during the course of this clerkship.

These clerkship objectives reflect the knowledge, skills and attitudes of the overall COM competencies and educational learning objectives as noted below. By the completion of the clerkship, students will be able to:

Topic 1: Demonstrate in depth knowledge in the care of the hospitalized internal medicine patient:

  • SLO 1.1: Utilize appropriate decision support resources and PDA/Smartphone resources in managing inpatient internal medicine problems
  • SLO 1.2: Analyze and apply principles of evidence based medicine in making diagnostic and management decision in internal medicine through the use of interpretation of current medical literature
  • SLO 1.3: Demonstrate the ability to apply appropriate clinical pharmacological principles in using medication to manage common inpatient internal medicine problems
  • SLO 1.4: Demonstrate the ability to conduct a focused medical history and targeted physical examination appropriate to the patient's chief complaint
  • SLO 1.5: Demonstrate the ability to diagnose and present a treatment plan for commonly occurring internal medicine illnesses in the inpatient setting
  • SLO 1.6: Formulate and apply effective transitions for patients between different care settings in the continuum of care
  • SLO 1.7: Demonstrate application of the principles of patient safety

Topic 2: Demonstrate understanding of the risks, benefits and indications appropriate to the level of education for the following procedures:

  • SLO 2.1: Arterial puncture
  • SLO 2.2: Insertion of nasogastric tube
  • SLO 2.3: Insertion of Foley catheter

Topic 3: Demonstrate the following professional and communication competencies:

  • SLO 3.1: Apply the biopsychosocial model and patient-centered method to the understanding of patient presentations in the inpatient setting
  • SLO 3.2: Demonstrate understanding of ethical principles and their application to patient care
  • SLO 3.3: Demonstrate effective communication skills with a diverse array of patients and members of the healthcare team in the inpatient setting
  • SLO 3.4: Apply principles of end-of-life care with a patient and family
  • SLO 3.5: Demonstrate the ability to clearly and concisely present oral and written summaries of patients to members of the healthcare team, with relevant information and synthesis of clinical information

Topic 4: Demonstrate understanding of the following broad inpatient internal medicine topics:

  • SLO 4.1: Abdominal pain
  • SLO 4.2: Acute gastrointestinal bleeding
  • SLO 4.3: Acute neurologic changes, including seizure, stroke, TIA
  • SLO 4.4: Acute pulmonary edema
  • SLO 4.5: Acute renal failure
  • SLO 4.6: Altered mental status
  • SLO 4.7: Arrhythmias
  • SLO 4.8: Chest pain
  • SLO 4.9: Electrolyte disorders
  • SLO 4.10: Fever
  • SLO 4.11: Glycemic control, including diabetic ketoacidosis
  • SLO 4.12: Hypertensive emergencies
  • SLO 4.13: Nausea and vomiting
  • SLO 4.14: Pain management
  • SLO 4.15: Respiratory distress
  • SLO 4.16: Shock and sepsis
  • SLO 4.17: Substance abuse/overdose/drug withdrawal
  • SLO 4.18: Syncope

SLO: Specific Learning Objective

If unable to follow a patient with a diagnosis in any one of the categories listed, the student will be required to complete the case in the student's guide from the Clerkship Directors in Internal Medicine. This will be determined by the clerkship director based on weekly reviews of the CDCS data. Progress on reaching the objectives of the clerkship will be formally addressed at the mid-clerkship formative evaluation, and a plan for remediation will be constructed.

How the Course Will Achieve These Objectives

At the start of the clerkship, each student will identify at least three issues in internal medicine that they hope to learn during this rotation, along with a plan to achieve these objectives, such as extra readings, following extra patients, or completing extra cases in the student guide. The student will submit these to the Education Director through BlackBoard. The Education Director will work with the Clerkship Director to allow the student to gain knowledge about these topics. Identification of these topics by the end of the first week of the clerkship will be required.

This clerkship will be conducted at community hospitals chosen to provide students comprehensive experiences with hospitalized patients on internal medicine services. The students will spend four weeks with clerkship faculty physicians who care for hospitalized patients. Under the direct supervision of the clerkship faculty physician, each student will learn to identify, evaluate and prioritize treatment of medically complex inpatients.

Students will be required to work up a minimum of 3 new/undifferentiated patients each week in the inpatient setting. During the 4 week block, students will see 6 - 10 follow-up/established patients each week. If at any point the student is carrying less than 2 patients per day (follow-ups) s/he will pick up and assume care of a patient who is not a new admission to the hospital. The number of patients each student has responsibility for will be determined by the complexity of cases and the student's demonstrated ability to assume a role in the care of additional patients. Students will be expected to demonstrate involvement at the moderate to full level of participation in at 2/3 of their patient encounters. Students will be expected to have progressively more autonomy in management of their patients during the clerkship.

Students will also be required to attend lectures and conferences where available. In settings where lectures and conferences are not available, students will acquire learning materials via reading and case assignments arranged by the clerkship director, using the Student Guide from the CDIM Subinternship Curriculum or other sources. In addition, each student will meet with the clerkship director once per week during the clerkship for case presentations and discussions. A minimum of one patient presentation per clerkship will be assessed by the clerkship director. The clerkship director will oversee students' CDCS patient-log entries, assuring breadth of experience and avoiding duplication.

This is primarily an apprenticeship style experience with an IM clerkship faculty member. There will be experiential learning that each student will have with his/her clerkship faculty. Students will also have the opportunity to learn about many of the ancillary services that occur inside and outside the hospital setting.

Clerkship directors will meet with the student at least once per week. The student will give a case presentation of a selected case at this weekly meeting. The student will be responsible for completing any assigned readings as well as being prepared for the educational interaction. The clerkship director will assess progress on the student's self-learning. A mid-point (formative) evaluation will be completed by the clerkship director. A daily electronic log of patients will be kept by the students and transmitted weekly to the Clerkship Director, who will insure that appropriate numbers of patients are being seen, and that the patient mix reflects common internal medical problems without undue duplication

Didactic sessions will be available through morning report, grand rounds, morning lectures and/or a noon lecture series. These sessions will be available based on location and the clerkship faculty's schedule. Each student will be given an updated monthly schedule indicating available learning opportunities. These sessions will be considered supplementary to the learning objectives of the clerkship and will be substituted with assigned readings and/or sessions with the clerkship director if needed.

Evaluation of students' charting of progress notes and discharge summaries will be done by the clerkship faculty member in the course of patient care activities.

The web-based NBME Internal Medicine Subinternship Exam will be given on the last day of the clerkship.

Each student will be required to meet with the clerkship director during the final week of the clerkship to debrief the clerkship director about the student's experiences on the clerkship. A final substantive evaluation will be completed by the clerkship director with input from clerkship faculty.

Scheduled Hours/On-Call

The clerkship is four weeks in duration and will consist of inpatient shifts, in-house call, lectures, conferences, and reading assignments. The student will work 12 hours per day or 6 days per week, with night call no greater than every 4th night, including weekend call. The student will be expected to be on call one weekend day/night during two of the four weekends during the rotation. The final call schedule will be determined based on the clerkship faculty member's call schedule. Students will adhere to the ACGME rules regarding the workweek, which include working no more than 80 hours per week, no more than 24 hours continuously, except an additional 6 hours may be added to the 24 to perform wrap-up duties, and have at least one of every 7 days completely off from educational activities.