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Goals and Objectives

Medicine Clerkship Goals and Objectives with Corresponding Entrustable Professional Activity (EPA)

 

Goal 1: Professionalism: Caring, Character and Clinical Competence (~10%* )

Objectives:

1. Treat all patients, staff, and colleagues with respect. This includes the following:

• Displaying good manners

• Displaying sensitivity to cultural differences

• Adhering to the dress code

• Avoiding confrontations

2. Display honesty which includes the following:

• Showing discernment while avoiding deception when communicating with patients and their families

• Not passing others’ work off as your own

• Adhering to the Honor Code

3. Demonstrate caring towards patients and their families, colleagues, faculty, and all members of the health care team (including staff), which includes the following:

• Effectively communicating empathy

• Putting patients’ needs above your own (altruism)

4. Demonstrate a good work ethic, which includes the following:

• Showing intellectual curiosity

• Accepting responsibility for your patients

• Being prepared and on-time

• Being accountable

• Being dependable

• Reliable attendance and participation (refer to page 28, College of Medicine Policies)

5. Strive for excellence

• Actively seek to help

• Actively seek to broaden education and experience beyond clerkship requirements

• Avoid complaining

6. Accurately self assess (this overlaps with PBLI and also will be addressed under that competency)

• Actively seek and apply feedback

• Give feedback (including filling out course and teaching evaluations in a timely manner)

• Convey humility

Learning Activity: Professionalism should imbue all aspects of your performance and cannot really be taught in isolation. However, reflection is a way to help maintain professional behavior. There are many activities in the portfolio that can promote this. Each student will participate in a small group discussion of reflective writings.

Evaluation: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument. Brief summaries of the formative feedback sessions should be entered in the portfolio. A copy of the actual feedback form does not need to be uploaded. Portfolio advisors will evaluate portfolio submissions and your interactions with them as well (including timeliness, attitude, initiative). How you treat staff, nurses, and all members of the health care team can play a role in this evaluation.

Goal 2: Patient Care (~30%*)- Evaluate and manage patients hospitalized with acute illness.

EPA 1: Gather a history and perform a physical examination

Objectives:

1. Obtain and record a patient’s history in a logical, organized, and thorough manner.

Learning activity: Interview, examine, and write an H&P for each new patient assigned to you (even if there is already a note). You must admit a minimum of two new patients per week.

Evaluation: H&Ps are submitted in the portfolio and the portfolio advisor is primarily responsible for evaluating these. The ward attending will give feedback as well, if specifically asked and provided a copy of the H&P. The four best H&Ps are included in the final portfolio for additional evaluation by the Clerkship Directors.

2. Perform and record a complete physical examination in a logical, organized, and thorough manner for new patients and an appropriately focused physical examination for follow up patients.

3. Be able to recognize normal from abnormal physical findings and identify the following  abnormalities:

a. Pulmonary crackles and wheezes

b. Extra heart sounds, systolic vs. diastolic murmurs, and specifically aortic stenosis and mitral regurgitation

c. Stigmata of liver disease

d. Lymphadenopathy

e. Jugular venous distension

Learning Activity: Each student should be observed performing a complete physical examination and or targeted portions of the exam that include cardiovascular, pulmonary, lymph nodes, abdomen. Harrell Center activities will be arranged to review abnormal heart sounds. Physical finding rounds will be offered to supplement students’ skills. Self-directed learning through online learning resources. Students can also lead peers in phycial finding rounds.

Evaluation: House staff and faculty will observe students performing physical examinations in the course of patient care and these observations will inform the summative evaluation. Evaluation forms to use for a formal, observed complete physical examination as well as mini-CEX forms for focused exams are available online to print and give to house staff and faculty to use when evaluating examination skills. These or a brief reflection on what was learned may be submitted in the portfolio.

EPA 3: Recommend and interpret common diagnostic and screening tests

4. Interpret important supplemental information, including CBC, serum chemistries, pleural/peritoneal chemistries, ABG, coagulation studies, urinalysis, chest x-ray, and ECG.National IM Clerkship Objectives for ECG Interpretation

Learning activity: Students are provided online learning resources to practice interpreting these tests. Students will be provided an ECG teaching packet supplemented by two small group activities.  ECGs, labs, and radiology images will also be reviewed with the team on rounds.

Evaluation: Students’ understanding of these tests will be assessed in small group discussions on rounds and on the NBME subject exam.

EPA 2: Prioritize a differential diagnosis following a clinical encounter

5. Use clinical reasoning to synthesize data into a prioritized differential diagnosis that clearly states a working diagnosis, to guide initial diagnostic evaluation and disease management.

Learning activity: This will be discussed on daily rounds with the teams, practiced using the online, interactive SIMPLE cases, and the clinical reasoning process is explicitly taught in the twice weekly “doc in the box” small group sessions.

Evaluation: This is assessed by the teams on daily round interactions and review of progress notes. This is also assessed formally in the portfolio with the H&Ps. Students select 4 of the (at least) 16 H&Ps that they complete during the clerkship that best demonstrate their clinical reasoning and medical decison making skills to include in their final portoflio. These 4 H&Ps are assessed by the clerkship directors. THIS IS A VERY IMPORTANT PART OF THIS CLERKSHIP. Students will take a 45 minute “key features” examination mid-clerkship that assesses clinical decision making. This exam will be used for formative feedback only. It will NOT contribute to the student’s grade.

Requirements: Students must complete a minimum of 16 patient write-ups to meet this objective, which is in line with the requirement to work-up a minimum of two new patients per week. Students are strongly encouraged to submit evidence of observed physical exams and oral presentation skills using the mini-CEX forms.

EPA 4: Enter and discuss orders and prescriptions

Although not a major objective of this clerkship, you are encouraged to pend orders for your patients and discuss them with the team.

Goal 3: Medical Knowledge (~15%*)- Demonstrate understanding of the clinical presentation, basic pathophysiology, evaluation and management of diseases frequently encountered in an inpatient medicine setting.

Objectives:

1. Review the pathophysiology and be able to recognize and initiate evaluation and management plans for the following disease states/clinical presentations that are recommended in the national Clerkship Directors of Internal Medicine Core Curriculum http://www.im.org/toolbox/curriculum/coremedicineclerkshipcurriculum/Documents/OnlineCDIMCurriculum.pdf (this link takes you to the detailed curriculum, which would work well as a study guide)

• Abdominal pain (SIMPLE case 9 &12)

Acute mental status alteration (SIMPLE cases 25& 26)

Acute myocardial infarction/acute coronary syndrome (SIMPLE case 1)

Acute renal failure (SIMPLE case 33)

Anemia (SIMPLE case 19)

• Arrhythmia (SIMPLE case 3)

• Asthma

• Anxiety

• Back pain (SIMPLE cases 27 & 34)

Cancer: common malignancies (lung, colon, breast, prostate, skin) (SIMPLE cases 17 , 27)

Cancer: less common malignancies

Cardiovascular disease (SIMPLE cases 2&4)

• Chest pain (SIMPLE case 2)

Chronic kidney disease (SIMPLE case 23)

• Chronic obstructive lung disease (SIMPLE case 28)

• Common geriatric issues (dementia, incontinence, falls, osteoporosis) (SIMPLE cases 13 & 18)

• Cough (SIMPLE case 22)

• Depression (SIMPLE case 5)

Diabetes Mellitus (SIMPLE case 7&8)

• Dizziness (SIMPLE cases 3 & 7)

• Dyslipidemia (SIMPLE case 16)

• Dyspepsia/ Peptic ulcer disease (SIMPLE case 10)

• Dysuria/urinary tract infections (SIMPLE cases 14 & 21)

Fever (SIMPLE cases 27, 29 & 35)

Fluid, Electrolyte, Acid/base disorders (SIMPLE cases 7, 25, 26, & 27)

• Gastrointestinal bleeding (SIMPLE cases 10 & 21)

• Headache (SIMPLE case 24)

• Heart failure/valvular heart disease (SIMPLE case 3)

HIV (SIMPLE case 20)

Hypertension (SIMPLE case 6)

• Joint pain (SIMPLE cases 31 &32)

Liver disease (SIMPLE cases 11 & 36)

• Lower respiratory tract infection (SIMPLE case 22)

• Meningitis (SIMPLE case 24)

• Nosocomial infection (SIMPLE cases 24)

• Obesity (SIMPLE case 16)

• Palliative care principles (SIMPLE case 27)

• Pancreatitis (SIMPLE case 9)

• Rash (SIMPLE case 17)

• Rheumatologic disorders (RA, spondyloarthropathies, SLE, systemic sclerosis, Sjogren syndrome, vasculitides, polymyositis, dermatomyositis) (SIMPLE case 32)

Sepsis (SIMPLE cases 21 & 24)

Shortness of breath (SIMPLE cases 4, 22, & 28)

• Substance abuse (SIMPLE cases 9,15 & 26)

• Syncope (SIMPLE case 3)

• Thromboembolic disease (SIMPLE case 30)

• Thyroid disorders

Learning activities: Many of these topics are covered in the interactive “doc in the box” teaching sessions. Expert faculty will meet with students for case based noon conferences to reinforce many of the concepts taught in the SIMPLE cases and of course students will actively care for patients with many of these medical problems. The above list also is intended to help guide students’ reading. Students are strongly encouraged to learn about all of their patients’ past medical problems in addition to the acute problems to further enhance their medical knowledge. (Completion of eight SIMPLE cases is a requirement of this clerkship. Students may select the cases that best fit their learning needs.)

Requirements: Students must provide evidence of patient exposure to the core presentations/problems that are in boldface above by using the patient logs. SIMPLE cases may substitute for an actual patient when students do not have the opportunity to care for a patient with one of the required presentations. The patient logs are a College of Medicine graduation requirement. There is no penalty to an incoplete log on this clerkship because students will have the opportunity to see any missed required presentations during the subinternship and/or required Emergency Medicine clerkship. Evidence of logging is a clerkship requirement. Each student will receive a summary of the required presentations that were not logged during this clerkship to help them identify cases to seek out on future rotations. Students who do not show evidence of logging (e.g. <10 entries) will have a point deducted from the PBLI competency.

Assessment methods: National Board of Medical Examiners subject exam (multiple choice) in internal medicine.

Goal 4: Communication and Interpersonal Skills (~15%*) Establish effective communication to identify and respond to each patient’s emotional needs and their personal desires regarding their medical treatment. Communicates effectively with team members to enhance team dynamics and patient care.

Objectives:

1. Establish effective rapport with patients and their families.

2. Speak clearly to patients and their families using language they can understand (avoid medical jargon).

3. Convey empathy to patients from a variety of cultures and backgrounds.

4. Keep team informed of patients’ progress and communicate with other healthcare members outside the team as needed.

Learning activities: Students will speak to patients and their families daily. Students will observe, and when appropriate, actively participate in more advanced communications with patients and their families such as breaking bad news, obtaining informed consent, obtaining advanced directives, and explaining new diagnoses or treatments.

Assessment methods: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument. Students have the option to have patients and families evaluate their communication skills using a structured patient evaluation questionnaire provided by the clerkship.

EPA 6: Provide an oral presentation of a clinical encounter

6. Orally present a patient’s history, physical examination, lab data, assessment and plan clearly, concisely, yet with appropriate detail.

Learning activity: This is practiced on daily rounds with the whole team present. More comprehensive presentations are typically performed with the attending or resident one-on-one and feedback is given at that time.

Evaluation: Attending and residents who directly observe this will provide formative and summative feedback. A mini-CEX form is available online to enhance this feedback and that may be included in the portfolio.

EPA 5: Document a clinical encounter in the patient record

7. Write cogent, clear progress notes that are up to date and document working diagnoses and status of diagnostic evaluation and therapeutic plans.

Learning activity: Students practice this by writing daily progress notes on all their patients. Daily progress notes are a clerkship requirement. These should be in the EMR in a timely manner (ideally before noon conference). EPIC templates are not allowed.

Evaluation: Progress notes are primarily evaluated by the house staff. To ensure adequate feedback, student should ask residents and faculty if they would prefer to have notes from the EMR printed and handed to them. Students also have the option of submitting them in the portfolio for additional feedback by the portfolio advisors.

Goal 5: Practice-based Learning (~15%*)- Develop skills that foster life-long learning habits

Objectives:

1. Based on self-assessment and the clerkship objectives, create a set of personal SMART goals for the clerkship and reflect on your progress, modifying as necessary.

2. Actively seek feedback and perform reflection and self-assessment routinely.

EPA 7: Form clinical questions and retrieve evidence to advance patient care

3. Apply EBM skills in real time to patient care

Learning activities: Students will create an Educational Portfolio with guidance from a faculty advisor, the content of which is partially driven by self-identified learning needs as identified in the goals and formative feedback. The portfolio will include EBM.

Requirements: Educational portfolio that includes SMART goals, formative feedback, and EBM.

Assessment methods: The Clerkship Directors and the designated portfolio advisor will review the student’s educational portfolio. Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument.

Goal 6: Systems-based Practice (~10%*) Work effectively as part of a team. Develop an understanding of resources needed by patients and the resources and limitations of the current health care system.

EPA 9: Collaborate as a member of an interprofessional team

1. Work as an effective member of the patient care team, demonstrating reliability, initiative, organization, and helpfulness.

EPA 13: Identify system failures and contribute to a culture of safety and improvement

2. Gain an understanding of interprofessional coordination and planning required when transitioning patients from the inpatient to outpatient setting.

3. Act as your patients’ advocate.

4. Practice high value care

Learning activities: Work with house staff and care managers one-on-one to help recognize and meet patients’ specific needs for interprofessional services or other supports both in the hospital and after discharge. Discuss cases with consultants and the non-physician members of the health care team when they are involved. Make post discharge phone calls to follow-up your patients using a checklist that is found in the portfolio and reflect on any implications to patient safety and quality of care. Every student should complete the High Value Care modules A and E located in MedU site where SIMPLE is found. Students not participating in the HVC study should complete 4 additional HVC modules. (Students assigned to Shands gold and blue medicine teams are assigned to the HVC study and do not need to select 4 additional modules.)

Assessment methods: Daily participation on work rounds, progress notes, and discharge planning paperwork will be assessed by the attending physician and house staff and feedback given at that time and through a structured evaluation instrument. A log and reflection on post discharge follow-ups will be submitted in the educational portfolio assessed by the portfolio advisor and/or Clerkship Directors.

Global Assessment: Formative and Summative Feedback

In addition to the specific assessment methods detailed for each competency, many of which are primarily formative feedback, students are required to meet with each attending physician mid-rotation for global formative feedback using the clerkship evaluation form found on the website under “evaluations”. Students are STRONGLY encouraged to seek formative feedback from all team members with whom they work. Summative feedback that assesses performance in all six competencies occurs at the end of each 4 weeks using an electronic, structured evaluation instrument with performance-based rating anchors.

*Percentiles in parentheses represent each competency’s approximate contribution towards the final clerkship evaluation.