Third Year

2010-2011 Course Syllabus

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Faculty

Jonathan S. Appelbaum, M. D., Director, Internal Medicine Education
Cynthia Powell, M. D., Clerkship Director, Orlando
Robert Anderson, M. D., Clerkship Director, Pensacola
Kathleen Kennedy, M. D., Clerkship Director, Sarasota
Michael Forsthoefel, M.D., Clerkship Director, Tallahassee
Vinnie Purandare, M.D., Clerkship Director, Daytona Beach

William Hood, M.D., Clerkship Director, Ft. Pierce
Rudy Hehn, M.D., Site Director, Thomasville
Steven Spence, M.D., Site Director, Rural Site

Clerkship Faculty from each regional campus

COURSE DESCRIPTION

The third year Internal Medicine Clerkship is an eight-week clinical rotation. The objective of the clerkship is to acquaint the student with the varied aspects of medical care for adults. Emphasis will be placed on enhancing the skills of taking a history, performing a physical examination, presenting these findings, and developing a differential diagnosis for common clinical presentations and problems. The skills of data analysis and critical thinking about diseases in patients will be highlighted.

Students will participate in the evaluation and care of outpatients and inpatients under the supervision of the College of Medicine internal medicine faculty physicians. Exposure to common procedures encountered in the practice of internal medicine will also be expected. Formal and informal daily teaching sessions and rounds with the clerkship faculty physician (and residents at some sites) are a major part of the eight-week experience. Clerkship directors at the regional campuses will meet with students once per week for teaching, evaluation and feedback. Each student will record and present appropriate clinical data daily to their clerkship faculty member. At least two clinical observations for each student will be performed by the clerkship director or clerkship faculty during the clerkship. Every student will work with a general internist four days per week for five weeks and then a hospital based clerkship faculty physician four days per week for three weeks or alternative similar exposure to inpatients and outpatients such that the student has exposure to caring for at least 20 hospitalized patients. The Doctoring 3 and Longitudinal Clerkship courses, which run concurrently with clerkships throughout the entire third year will place the student with a community-based longitudinal faculty member for one half-day every week and in the didactic sessions at the regional campus for one half-day every week.

Course Objectives

These clerkship objectives reflect the knowledge, skills and attitudes of the overall COM
Specific Learning Objectives (SLO) as noted below. By the completion of the clerkship, students will be able to:

Demonstrate knowledge of Ambulatory Internal Medicine

  • Demonstrate the ability to conduct a focused medical history and targeted physical examination appropriate to the patient’s chief complaint(s) and the history of the present illness(es) in internal medicine
  • Manage appropriate decision support resources such as treatment guidelines in caring for patients
  • Choose principles of evidence-based medicine in making diagnostic and management decisions in internal medicine
  • Demonstrate the ability to apply appropriate clinical pharmacological principles in the selection of drugs to treat common internal medicine problems
  • Demonstrate the ability to perform a health maintenance examination appropriate for an adult and to apply appropriate prevention and screening guidelines
  • Assess the importance of and screen for specific geriatric syndromes such as dementia, delirium and the propensity to fall in the older aged populations
  • Demonstrate the ability to document an outpatient visit using the SOAP note

Demonstrate knowledge of Inpatient Internal Medicine

  • Demonstrate the ability to perform an admission history and physical examination
  • Demonstrate facility in the application of medical informatics technology and critical appraisal of the medical literature in making diagnostic and management decisions in internal medicine
  • Write admission orders for common inpatient internal medicine problems
  • Demonstrate the ability to construct a hospital progress note

Demonstrate the ability to understand the indications, risks and benefits and be competent to his/her level of education for the following procedures

  • Administration of intramuscular, subcutaneous and intradermal injections
  • Universal precautions
  • Obtain wound cultures
  • Perform and interpret ECGs
  • Interpret chest x-ray

Apply the following in professional and patient interactions:

  • Demonstrate the ability to apply the biopsychosocial model and patient-centered clinical method to the understanding of patient presentations
  • Demonstrate a basic understanding of ethical principles and their applications to patient care
  • Demonstrate effective communication skills with a diverse array of patients, physicians and other health team members
  • Demonstrate a basic understanding of how age, gender, race, cultural and socioeconomic class effects the management of internal medicine patients
  • Using the patient’s history, physical exam, laboratory and imaging results to construct appropriate differential diagnoses
  • Demonstrate the ability to diagnose and construct a treatment plan for common illness in internal medicine (see Broad Topic Areas below)
  • Demonstrate the use of PDA resources in the clinic
  • Demonstrate the ability to clearly and concisely present oral summary of patients to members of the health care team in an allotted period of time

Broad Topic Areas

The student should have an understanding of the following topics, commensurate with their level of training. Students will be required to evaluate the following categories of problems/diagnoses in new or established patients:

Preventative Care and Health Maintenance –including screening for appropriate risk factors. Students will have the opportunity to continue disease screening from other clerkships.

Elder Care –focusing on geriatric syndromes such as delirium, dementia and fall risk

Cardiovascular Disease (for example: hypertension, coronary artery disease, arrhythmia, heart failure)

Renal Disease (for example: acute renal failure, chronic renal failure and glomerular disease)

Gastrointestinal Disease (for example: abdominal pain, peptic ulcer disease, gastritis, reflux, bleeding)

Cerebrovascular Disease (for example: stroke, transient ischemic attack, seizure, headache)

Endocrinology(for example: diabetes, thyroid disease, dyslipidemia, obesity)

Infectious Disease (for example: hospital acquired infections, cellulitis, pneumonia, UTI, HIV/AIDS)

Hematology/Oncology (for example: common malignancies, anemia)

Musculoskeletal Disease (for example: back pain, osteoarthritis, autoimmune diseases)

Pulmonary Disease (for example: COPD, asthma, interstitial lung disease)

If unable to gain access to a patient with a diagnosis in any one of the categories listed, the student will be required to complete a reading assignment or a case with a diagnosis/problem in that category. The need for completing the reading assignment will be determined by the clerkship director based on weekly reviews of the CDCS data, which will be discussed with the student on a weekly basis.

M3 INTERNAL MEDICINE CLERKSHIP STUDENT SELF-STUDY PROGRAM

This self-study program has been designed to assist the student in managing the vast amount of medical information available. This program will result in exposure to the core concepts and breadth of knowledge deemed necessary for students to have acquired during this clerkship. The keys to success during this rotation include a daily text reading program covering not only the clinical encounters of the day, but also enough to cover the assigned readings by the end of the clerkship.

Internal Medicine cases, known as Case Files, are an integral part of the clerkship learning experience. Students are to complete at least the assigned cases and the readings in Harrison’s or Andreoli and Carpenter’s Cecil Essentials of Medicine 7 Edition. While the student is only responsible for the cases listed below, the student is encouraged to read all of the cases.

TEACHING AND LEARNING METHODS

This is primarily an apprenticeship style experience with a single internal medicine 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 of the hospital setting.

Clerkship directors will meet with students at least once per week. A general medicine topic will be discussed at this weekly meeting. The discussion may include the following: review of the assigned internal medicine Case Files, discussion of an interesting case seen during the week, a review of materials read prior to the meeting, a brief review of an ethics topic developed by a faculty ethicist. CDCS entries will be reviewed and suggestions for learning any uncovered topics/diagnoses will be made by augmenting clinical experiences, completing internal medicine Case Files or paper cases and/or completing reading assignments. Students are expected to demonstrate involvement at the moderate to full level of participation in at least 2/3 of their patient encounters.

Didactic sessions may be available through grand rounds, morning lectures, noon lectures, and and/or sessions with the clerkship faculty member or clerkship director, depending on location and the clerkship faculty’s schedule. Each student will be informed of their local learning opportunities and are encourage to participate.

The clerkship directors or clerkship faculty will observe and verify that each student has met competency standards in the performance of these areas:
History and Physical Examination
Oral Case Presentation
Chart Documentation
Clinical Diagnostic Decision Making (Critical Thinking)

In addition, the clerkship faculty and clerkship directors will monitor the students’ activities to ensure that they are exposed to the procedures listed below, especially if the student has not had this experience on a prior clerkship. If this criteria is not met and the clerkship faculty member or clerkship director is unable to assist the student with gaining exposure to the procedure (s) in an alternate manner, the clerkship director will notify the Education Director as well as the campus dean that the student still needs to complete the procedure (s). The student will then be expected to gain exposure to the procedure (s) on a subsequent clerkship. Procedures the student is expected to gain exposure to on the IM clerkship include, but are not limited to:

Administering intramuscular, subcutaneous and intradermal injections

Demonstrating universal precautions

Obtaining wound cultures

Performing AND interpreting EKG

Interpreting chest x-ray

Students are encouraged to participate in inter-clerkship disease screening and referral programs such as:

Tobacco use screen (“Have you used tobacco products within the last 30 days?”)

Depression

Substance abuse

Domestic violence, including elder abuse

Osteoporosis risk

Falls risk/prevention

Pain

Urinary incontinence

Sexual concerns

others

Call and weekends
Students will be on-call at the discretion of the clerkship faculty during the five weeks outpatient component of the clerkship. The call frequency will not exceed every 4th night. The student will be on call every 4th night during the two weeks inpatient component of the clerkship and will be expected to remain in house until 11pm or as directed by the clerkship faculty or resident working with the clerkship faculty member. Each student will work at least two weekend days per eight-week clerkship unless otherwise directed by clerkship faculty.

EVALUATION METHODS

Since this clerkship is an apprentice-style experience, direct clinical observation by internal medicine faculty will be the primary method of student evaluation. Active participation in the weekly meetings with the clerkship director will be another means of assessing student performance. Finally, the NBME Internal Medicine Subject Examination will assess overall knowledge of internal medicine and will allow the student to compare him/herself to peers.

Students will also be evaluated in two other ways. First, a timed oral case presentation to clinical faculty, done near the end of the clerkship, will assess case presentation skills, which is one of the course objectives. Second, the student will submit a self-assessment of his/her growth in knowledge of internal medicine and discuss some topic areas where the/she would have liked to have learned more, and the ways he/she hopes to remediate this deficiency. This self-assessment will be submitted to the Education Director through BlackBoard during the final week of the rotation.

A post-clerkship debriefing may be held as a group with the clerkship director at the end of the clerkship.