Goal 1: Professionalism: Caring, Character, and Clinical Competence
Unprofessional behavior will result in a lowering of your grade and potentially an unsatisfactory evaluation for the entire clerkship with appearance before the Academic Status Committee.
- 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)
- 90% attendance in clerkship seminars, workshops, and lectures
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. Each student will participate in a small group discussion of reflective writings. Peer evaluations are another way to get feedback on how you are perceived as a professional. There is an optional peer evaluation tool you may use and these should be submitted to Ms. Pipkins.
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 submitted at the end of the clerkship. A copy of the actual feedback form does not need to be uploaded.
Goal 2: Patient Care – Evaluate and manage patients hospitalized with acute illness.
- EPA 1: Gather a history and perform a physical examination
- EPA 3: Recommend and interpret common diagnostic and screening tests
- EPA 2: Prioritize a differential diagnosis following a clinical encounter
- EPA 4: Enter and discuss orders and prescriptions
- (EPA= Entrustable Professional Activity)
- Obtain and record a patient’s history in a logical, organized, and thorough manner.
Learning activity: Interview, examine, and write a complete 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, minimum of 16 patients per rotation.
Evaluation: Any H&P can be evaluated by your peers and you may revise your H&P based on peer feedback. You must give at least one H&P per month (2 over 8 weeks) to your IM coach to make sure you are on the right track. You may NOT revise the H&P at this stage but you can apply feedback provided to future H&Ps. The ward attending will give feedback as well, if specifically asked and provided a copy of the H&P. Further, Dr. Nall or Dr. Sottile will give you feedback and a score on a write up during your mid-point feedback session. If you are happy with the score you can use this write up as one of the four write ups submitted at the end of the clerkship for grading. If you do not use this write up at the end of the rotation from the minimum of 16 H&Ps you completed, select your four best H&Ps for grading. These will be evaluated by the Clerkship Directors as part of your grade.
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:
- Abnormal thyroid size/goiter
- Pulmonary dullness, crackles, and wheezes
- Jugular venous distension
- Extra heart sounds (specifically S3), systolic vs. diastolic murmurs, and specifically aortic stenosis and mitral regurgitation
- Abnormal arterial pulses (bruit, irregular rhythm, absence)
Learning Activity: Each student should be observed performing a complete physical examination and MUST be observed performing targeted portions of the exam that include cardiovascular, pulmonary, and thyroid. Simulation activities will be arranged to review abnormal heart sounds and thyroid. Physical finding rounds will be offered to supplement students’ skills. Self-directed learning through online learning resources. IM coaches are available to observe parts of the physical exam if your teams have trouble finding time.
Evaluation: Housestaff 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 housestaff and faculty to use when evaluating examination skills. These or a brief reflection on what was learned may be submitted at the end of the clerkship. Students MUST be signed off on an abnormal physical finding card for the above abnormal findings. This card is turned in to Ms. Pipkins.
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. There is a dedicated conference to review chest imaging. Lab results, ECGs, and radiology images will be reviewed with the team on rounds.
Evaluation: Students’ understanding of these tests will be assessed in small group discussions on rounds, H&Ps, and on the NBME subject exam.
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 AQUIFER INTERNAL MEDICINE cases, and the clinical reasoning process is explicitly taught in the twice weekly “Doc in the Box” small group sessions. Completion of the twelve core AQUIFER INTERNAL MEDICINE cases is a requirement of this clerkship. Students may select the cases that best fit their learning needs but should pay close attention to the summary statement feature in each case.
Evaluation: This is assessed by the teams on daily round interactions and review of progress notes. This is also assessed 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 decision making skills to submit for evaluation at the end of the clerkship. These 4 H&Ps are assessed by the clerkship directors. Further, clinical decision making and medical decision making will be assessed by the Aquifer: Clinical Decision Making Exam at the end of the clerkship. THIS IS A VERY IMPORTANT PART OF THIS CLERKSHIP.
Requirements: Students must complete a minimum of 16 H&Ps to meet this objective, which is in line with the requirement to work-up a minimum of two new patients per week.
Goal 3: Medical Knowledge – Demonstrate understanding of the clinical presentation, basic pathophysiology, evaluation and management of diseases frequently encountered in an inpatient medicine setting.
- 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. This can be used as a study guide.
- Abdominal pain (AQUIFER INTERNAL MEDICINE cases 9,12)
- Acute mental status alteration (AQUIFER INTERNAL MEDICINE cases 25, 26)
- Acute myocardial infarction/acute coronary syndrome (AQUIFER INTERNAL MEDICINE case 1)
- Acute renal failure (AQUIFER INTERNAL MEDICINE case 33)
- Anemia (AQUIFER INTERNAL MEDICINE case 19)
- Arrhythmia (AQUIFER INTERNAL MEDICINE case 3)
- Back pain (AQUIFER INTERNAL MEDICINE cases 27, 34)
- Cancer: common malignancies (lung, colon, breast, prostate, skin) (AQUIFER INTERNAL MEDICINE cases 17, 27)
- Cancer: less common malignancies
- Cardiovascular disease (AQUIFER INTERNAL MEDICINE cases 2, 4)
- Chest pain (AQUIFER INTERNAL MEDICINE case 2)
- Chronic kidney disease (AQUIFER INTERNAL MEDICINE case 23)
- Chronic obstructive lung disease (AQUIFER INTERNAL MEDICINE case 28)
- Common geriatric issues (dementia, incontinence, falls, osteoporosis) (AQUIFER INTERNAL MEDICINE cases 13, 18)
- Cough (AQUIFER INTERNAL MEDICINE) case 22)
- Depression (AQUIFER INTERNAL MEDICINE case 5)
- Diabetes Mellitus (AQUIFER INTERNAL MEDICINE cases 7, 8)
- Dizziness (AQUIFER INTERNAL MEDICINE cases 3, 7)
- Dyslipidemia (AQUIFER INTERNAL MEDICINE case 16)
- Dyspepsia/ Peptic ulcer disease (AQUIFER INTERNAL MEDICINE case 10)
- Dysuria/urinary tract infections (AQUIFER INTERNAL MEDICINE cases 14, 21)
- Fever (AQUIFER INTERNAL MEDICINE cases 27, 29, 35)
- Fluid, Electrolyte, Acid/base disorders (AQUIFER INTERNAL MEDICINE cases 7, 25, 26, 27)
- Gastrointestinal bleeding (AQUIFER INTERNAL MEDICINE cases 10, 21)
- Headache (AQUIFER INTERNAL MEDICINE case 24)
- Heart failure/valvular heart disease (AQUIFER INTERNAL MEDICINE case 3)
- HIV (AQUIFER INTERNAL MEDICINE case 20)
- Hypertension (AQUIFER INTERNAL MEDICINE case 6)
- Joint pain (AQUIFER INTERNAL MEDICINE cases 31, 32)
- Liver failure (AQUIFER INTERNAL MEDICINE cases 11, 36)
- Lower respiratory tract infection (AQUIFER INTERNAL MEDICINE case 22)
- Meningitis (AQUIFER INTERNAL MEDICINE case 24)
- Nosocomial infection (AQUIFER INTERNAL MEDICINE case 24)
- Obesity (AQUIFER INTERNAL MEDICINE case 16)
- Palliative care principles (AQUIFER INTERNAL MEDICINE case 27)
- Pancreatitis (AQUIFER INTERNAL MEDICINE case 9)
- Rash (AQUIFER INTERNAL MEDICINE case 17)
- Rheumatologic disorders (RA, spondyloarthropathies, SLE, systemic sclerosis, Sjogren syndrome, vasculitides, polymyositis, dermatomyositis) (AQUIFER INTERNAL MEDICINE case 32)
- Sepsis (AQUIFER INTERNAL MEDICINE cases 21, 24)
- Shortness of breath (AQUIFER INTERNAL MEDICINE cases 4, 22, 28)
- Substance abuse (AQUIFER INTERNAL MEDICINE cases 9,15, 26)
- Syncope (AQUIFER INTERNAL MEDICINE case 3)
- Thromboembolic disease (AQUIFER INTERNAL MEDICINE 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 AQUIFER INTERNAL MEDICINE 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 twelve core AQUIFER INTERNAL MEDICINE cases is a requirement of this clerkship.)
Requirements: Students must provide evidence of patient exposure or completion of the Aquifer Internal Medicine case for the 12 core presentations that are in boldface above by using the patient log in New Innovations. AQUIFER INTERNAL MEDICINE 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 and must be logged in New Innovations the same as an actual patient. Students are responsible for keeping track of their logs. The patient logs are a College of Medicine graduation requirement. Each student will receive a summary of their patient log at the end of the clerkship. Incomplete logs will result in a “H” hold on the grade until the appropriate AQUIFER INTERNAL MEDICINE case(s) is(are) completed. It may also result in a subtraction of up to 1 point from the PBLI competency.
Assessment methods: National Board of Medical Examiners subject exam (multiple choice) in internal medicine and the Aquifer Clinical Decision Making Exam.
Goal 4: Communication and Interpersonal Skills – Establish effective communication to identify and respond to each patient’s emotional needs and their personal desires regarding their medical treatment. Communicate effectively with team members to enhance team dynamics and patient care.
- EPA 6: Provide an oral presentation of a clinical encounter
- EPA 5: Document a clinical encounter in the patient record
- Establish effective rapport with patients and their families.
- Speak clearly to patients and their families using language they can understand (avoid medical jargon).
- Convey empathy to patients from a variety of cultures and backgrounds.
- 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. Feedback will be provided by the students inpatient teaching team and patients.
Assessment methods: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument. Students have the option (not required) to have patients and families evaluate their communication skills using a structured patient evaluation questionnaire provided by the clerkship.
- Orally present a patient’s history, physical examination, lab data, assessment and plan clearly, concisely, yet with relevant details.
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 feedback is given at that time. Dr. Nall will lead optional small group practice sessions that you can sign up for on the sign-up sheet posted on the door of the clerkship office. IM coaches and peers are another venue to practice this difficult skill.
Evaluation: Attendings and residents who directly observe this will provide formative and summative feedback.
- 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 housestaff. 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 reviewing them with their IM coach.
Goal 5: Practice-based Learning – Develop skills that foster life-long learning habits
EPA 7: Form clinical questions and retrieve evidence to advance patient care
- 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. These SMART goals should be brought to the mid-point clerkship meeting.
- Actively seek feedback and perform reflection and self-assessment routinely.
- Apply EBM skills in real time to patient care
Learning activities: Students will develop goals with guidance from their IM coach and meet either individually or with their “teamlet” to review their progress and revise their goals as needed. Students will reflect on their progress. Students must obtain formative feedback, using the formative feedback form, from attendings and housestaff with whom they worked the most. This can be done individually or with several team members at once (e.g. residents and faculty). There are many opportunities for students to practice EBM skills and these are outlined in the EBM section of the website.
Assessment methods: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument.
Goal 6: Systems-based Practice – 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
- EPA 13: Identify system failures and contribute to a culture of safety and improvement
- Work as an effective member of the patient care team, demonstrating reliability, initiative, organization, and helpfulness.
- Gain an understanding of interprofessional coordination and planning required when transitioning patients from the inpatient to outpatient setting.
- Act as your patients’ advocate.
- Practice high value care
Learning activities: Work with housestaff 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 and reflect on any implications to patient safety and quality of care. Every student must complete the High Value Care modules 1 and 5.
Assessment methods: Daily participation on work rounds, progress notes, and discharge planning paperwork will be assessed by the attending physician and housestaff and feedback given at that time and through a structured evaluation instrument. A log and reflection on post discharge follow-ups will be submitted at the end of the clerkship
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.