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Primary Care Ambulatory Clerkship

Syllabus - Clinical Curriculum

VIII.) Clinical Overview

The clinical portion of the Primary Care Ambulatory Clerkship will be offered at your base hospital site in the following configuration:

• 12 weeks of Multidisciplinary Primary Care Experiences - 4-week family medicine experience; 4-week general internal medicine experience; and 4-week general pediatrics experience
• 4-week Continuity Experience in family medicine
• 8 weeks of Specialty Ambulatory Experiences - 4-week PCAC Specialty Experience and 4-week PCAC Choice Rotation

The schedule for these experiences is normally 8:00-5:00 Monday through Friday, but can also include evenings and weekends, and should be planned for accordingly.

Criteria for primary care sites:

• Primary care philosophy—opportunities for continuity of care, providers from other disciplines, etc.
• Diversity of ages in patient population
• Diversity of diagnoses

Role of clinical instructor:

• Hold "opening rounds" to informally discuss upcoming pertinent cases
• Identify appropriate patients for the student
• Observe and validate student's history and physical exam findings
• Work with the student to develop an appropriate management plan
• Review and provide feedback on a student's SOAP notes/charting

IX.) Clinical Experience Objectives

Multidisciplinary and Continuity Experiences

Internal Medicine Rotation Objectives
By the completion of the PCAC, the student should have mastered the following skills and objectives associated with internal medicine

Cognitive Skills--the student should be able to:

1. Elicit and record a complete medical history in adults of various ages
2. Perform a complete physical examination
3. Elicit a focal history and perform a focused physical examination directed toward a specific problem
4. Use information from the history and physical examination to formulate a differential diagnosis
5. Integrate information from the history and physical examination and from diagnostic studies in medical problem solving
6. Formulate a basic management plan
7. Enter information appropriately in the medical record using the SOAP format
8. Present a patient case to other medical professionals
9. Write prescriptions under supervision
10. Interpret common laboratory tests
11. Interpret a PA and lateral chest x-ray and have an evolving knowledge of electorcardiography
12. Behave in a professional manner and relate well with patients, patients' families and other members of the health care team

Didactic Knowledge--the student should be able to:

1. Describe for patients of various ages the clinical presentation, pathophysiology, appropriate application of diagnostic tests and management of the following chronic adult heath conditions:
   
   Hypertension, diabetes, chronic obstructive pulmonary disease, ischemic heart disease, myocardial failure, hyperlipidemia and atherosclerosis, arthritis

2. Text, journal, and internet citations (see recommended texts for full citations):

• Full report of A.T.P. III
  NHLBI website at www.nhlbi.nih.gov
  
  JNC on Prevention Detection Evaluation and Treatment of high blood pressure
  www.nhlbi.nih.gov/guidelines/hypertension/
  Guidelines for the Evaluation and Management of Heart Failure ACC/AHA Task Force American College of Cardiology Vol. 26 (5) Nov 1, 1995, 1376-98.
  
  ACC/HAA Guidelines for Unstable Angina JACC Vol. 36 No. 3 Sept 2000:970-1062
  
  ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non-ST Segment Elevation Myocardial Infarction: Executive Summary and Recommendations.
  Circulation Sept 5, 2000
  Circulation 2000, 102 1193-1209
  www.circulationaha.org
  
  
• Harrison's Principles of Internal Medicine, 17th edition (2008)
  • Hypertensive Vascular Disease [230] 1463-1481
  • Diabetes [323] 2152-2180
  • Chronic Obstructive Pulmonary Disease [242] 1547-1554
  • Ischemic Heart Disease [226] 1434-1444
  • Heart Failure and Cor Pulmonale [216] 1367-1378
  • Disorders of Lipoprotein Metabolism [335] 2286-2303
  • Rheumatoid Arthritis [301] 1968-1977
  • Osteoarthritis [312] 2036-2045
• Swartz, Mark H. (2005). Textbook of Physical Diagnosis, 5th edition
• Dubin, Dale (2000). Rapid Interpretation of EKGs, 6th edition
• Ward, R. C. (Ed.) (2003). Foundations for Osteopathic Medicine, 2nd edition

Pediatric Rotation Objectives
(NOTE: Added detail in the form of objectives, references and evaluation methods for each goal are included for clinical preceptors and students. In addition, you need to review "An Evening in the Life of a Pediatrician" and the Pediatric Review Questions found within your class PCAC Angel Group while on your Pediatric Rotation.)

EXPECTED COMPETENCIES IN PROFESSIONAL CONDUCT AND ATTITUDES DURING COM PCAC PEDIATRIC CLERKSHIP:

Goal 1: The student will consistently demonstrate a caring attitude and express empathy with concerns of the patient and family.

Goal 2: The student will consistently demonstrate conscientiousness in carrying out assignments.

Goal 3: The student will consistently demonstrate curiosity as a vital component of adult learning.

Goal 4: The student will exhibit commitment to cooperation and collaboration with physician colleagues and support staff.

Goal 5: The student will demonstrate a commitment to the values of the medical profession.

Goal 6: The student will demonstrate consistently a concern for ethical practice.

Goal 7: The student will demonstrate knowledge of and respect for cultural diversity.

Goal 8: The student will demonstrate a capacity for useful self-criticism.

EXPECTED COMPETENCIES IN COGNITIVE PERFORMANCE FOR THIRD YEAR MEDICAL STUDENTS DURING COM PEDIATRIC AMBULATORY CLERKSHIP:

Goal 1: The student will understand the rationale for and use of a well-organized problem-oriented record (POR).

Goal 2: The student will demonstrate understanding of growth and development through the first 21 years of life and apply that understanding to the evaluation and care of patients.

Goal 3: The student will understand and be able to justify the normal sequence of immunization, plans for catch-up immunization, and contraindications to immunization.

Goal 4: The student will understand and develop a plan for optimizing the nutrition of a normal infant.

Goal 5: The student will understand and offer anticipatory guidance appropriately, utilizing Bright Futures as a model.

Goal 6: The student will understand and be able to recognize physical abuse, sexual abuse, and neglect.

Goal 7: The student will be able to generate and prune, through judicious use of history and physical, appropriate differentials for the most common presenting problems from birth through age 21.

Goal 8: The student will develop an evidence-based, resource-sensitive approach to the use of laboratory and imaging studies for diagnosis.

Goal 9: The student will understand the challenges chronic illness poses for patients and their families.

Goal 10: The student will understand how to select appropriate evidence-based and ethically sound therapy for common outpatient conditions.

EXPECTED COMPETENCIES IN PSYCHOMOTOR SKILLS FOR THIRD YEAR MEDICAL STUDENTS DURING COM PEDIATRIC AMBULATORY CLERKSHIP:

Goal 1: The student will become a competent interviewer.

Goal 2: The student will convey information to families effectively.

Goal 3: The student will perform and document a competent age-appropriate physical examination.

Goal 4: The student will gain skill in documentation and some experience with prescription writing.

Goal 5: The student will gain knowledge about storage requirements and effective administration of vaccines and medications.

Family Medicine Rotation Objectives (Multidisciplinary & Continuity Experiences):

Goals: Expose students to practicing osteopathic physicians and their patients so that students can become familiar with the family practice method of health care delivery and the role of the family physician in the community. This experience will help the student refine skills of information data gathering, communication, physical examination, osteopathic manual medicine, differential diagnosis, patient relationships, clinical problem solving, and ethical decision making.

Objectives:

Cognitive Skills - At the end of the multidisciplinary and continuity family practice experiences, the student will have been exposed to and gained experience with, but not necessarily become proficient, in:

1. Understanding the nature of the physician-patient relationship and its impact upon the management of the patient's health status.
2. Assessing the patient, their community, social and family support in the context of the biopsychosocial model.
3. Using problem solving clinical skills with ambulatory patients who have undifferentiated early disease state problems.
4. Developing long-term treatment plans and goals for patients with chronic illness.
5. Assessing a patient's health risk status with appreciation for methods of education around disease prevention and health promotion.
6. Formulating differential diagnosis and treatment plans based upon limited information gathered in a brief office visit.
7. Refining time management skills.
8. Understanding patient problems in a community and family context.
9. Understanding patient problems in a health care delivery system context.

• Activity: Identify which traditional insurance and managed care products are accepted by your practice site, the type of product, and discuss how they affect patient care decisions concerning:
  • Consultations
  • Lab and x-ray
  • Hospitalization
• Is there a risk sharing involved in these arrangements?
• How did the physician work to gain needed services which were denied by the insurance company?

10. Recognizing how interpersonal relationships, social characteristics and cultural norms can alter the presentation and management of health and illness.
11. Understanding the reasons and proper utilization of consulting physicians.

• Activity: Review five patient consultations with respect to:
  • Purpose:
    • diagnosis
    • management
  • Initiated by:
    • primary care physician
    • patient
    • other physician
  • Transfer of information prior to consultation
  • Patient preparation and compliance
  • Evaluation of consultant information
  • Impact of managed care on consultation process

12. Development of skills related to self-directed lifelong learning.
13. Assessing changing health status on a yearly basis in continuing care.

Technical Skills - Certain fundamental skills are utilized on a day-to-day basis in a family physician's office. During the multidisciplinary and continuity ambulatory experiences, we expect the student to be exposed to and build upon prior experience and knowledge in the following areas:

1. Prescription-writing.
2. Completion of an office super bill.
3. Perform vitals including blood pressure, respiration and heart rate determination.
4. Perform components of the physical examination including OMM screen.
5. Perform venipunctures.
6. Appreciate the rationale and appropriate usage of a peak flow meter.
7. Perform case presentations on patients seen in the office as related to the SOAP note.
8. Utilization of medical resources (text, journals, medical informatics) to enhance patient care.
9. Utilization of medical informatics to increase information management skills.
10. Demonstration of proper use of metered dose inhalers.
11. Medical documentation and medical chart review with utilization of the SOAP format in recording.

• Activity: Describe the medical record:
  • Electronic vs. manual
  • Dictated notes vs. written
  • SOAP format vs. other
  • Standardized forms, list which are used
  • Clearly identified and easily useable sections on:
    • Physical exam data base
    • Progress notes, lab, x-ray, referrals, etc.
    • Problem sheet
    • Allergies, medications
    • Immunizations, health screening and maintenance of each specific health exams

12. Based on your current knowledge, construct a chart for your office
13. Appreciation for indications and contraindications of office procedures (osteopathic manipulation, flexible sigmoidoscopy, pulmonary function test, colposcopy, minor office surgery).
14. Intramuscular and subcutaneous administration of drugs and immunizations.
15. Basic EKG interpretation.
16. BCLS.

Didactic Knowledge - The didactic reading components for this six-week experience are based upon common presenting problems as seen by family physicians in their offices. The list of common symptoms and diagnoses have been identified by utilization of the National Ambulatory Survey and Ambulatory Training Standards. Strengthening a student's basic science and clinical understanding of common presenting complaints coupled with a hands-on experience with patients in the clinical setting will allow the students appreciation for the practice of family medicine.

Reading materials will focus on improving student's base knowledge of identified symptoms and diagnoses in the following areas: pathophysiologic appreciation of disease, common clinical presentation, physical examination findings, differential diagnosis, cost conscious work-up and basic management issues.

The list of symptoms and diagnoses include:

Specialty Ambulatory Experiences

The specialty ambulatory experiences must be 4 weeks in length-one service, one hospital, one block. Students choosing to do choice rotations outside their base hospitals must obtain an appropriate ID from that hospital. A PCAC Specialty / Choice application form must be completed online for each rotation.

PCAC Specialty Experience:

Goals:
The 4-week specialty experience in the PCAC is designed to introduce the student to an area of specialty medicine with an ambulatory office base.

Objectives:
For a specific rotation to qualify for this experience it should be approximately 40% office-based. Experiences can include a mix of ambulatory, hospital and other experiences. Scheduling is at the discretion of the base hospital and must occur within the student's base hospital. The rotation may be medically or surgically oriented and should constitute an experience that will develop a set of unique knowledge and skills that will enhance the individual's knowledge base and skills.

Specific objectives for this rotation include:

• Increased understanding of the relationship between primary care and specialty medicine.
• Increased understanding of the diagnosis, treatment and management of common problems.
• Increased familiarity with issues surrounding patient referrals.
• Increased familiarity with diagnostic testing and use of appropriate ancillary services.
• Increased skill development and knowledge of common procedures.

The following list provides examples of rotations that would meet this requirement but is not inclusive. Base hospitals within the MSUCOM SCS will determine which rotations are available. Students interested in a rotation not listed below should check with their DME concerning its availability.

The specialty experience category must differ from the category selected for the PCAC Choice Rotation

(NOTE: Students may take only 4 weeks of OMM in the Lansing community during the Clinical Clerkship Program.)

PCAC Choice Rotation:

Goal: The 4 week PCAC Choice Rotation is designed to allow students increased options to pursue areas of particular interest and to allow training sites greater flexibility in meeting curricular requirements.

Objectives:
PCAC Choice rotations must offer the student a minimum of 40% time in an office setting (four half-days per week in an office or other outpatient setting). The Ambulatory Choice Rotation may be taken at any MSUCOM base hospital offering the PCAC. The student, however, will be required to return to their base hospital for all scheduled PCAC didactic sessions. Students are encouraged, upon notification of their base hospital assignment, to make arrangements through the Directors of Medical Education (at least 30 days in advance) for their desired choice rotations.

Specific objectives for this rotation include:

• Increased understanding of the relationship between primary care and specialty medicine.
• Increased understanding of the diagnosis, treatment and management of common problems.
• Increased familiarity with issues surrounding patient referrals.
• Increased familiarity with diagnostic testing and use of appropriate ancillary services.
• Increased skill development and knowledge of common procedures.

Base hospitals within the MSUCOM SCS will determine which rotations are available. Students interested in a rotation not listed below should check with the DME concerning its availability. The following rotations may be considered for PCAC Choice Rotations:

Rotations not in this list may be considered for a PCAC Choice Rotation with approval of the base hospitals' DME and the PCAC Coordinator.

The choice rotation category must differ from the category selected for the PCAC specialty experience category

(NOTE: Students may take only 4 weeks of OMM in the Lansing community during the Clinical Clerkship Program.)

The broad objectives for the specialty and choice rotations you choose are:

Subspecialty Internal Medicine Rotation Objectives:

By the completion of the specialty ambulatory clerkship, the student should have mastered the following skills and objectives:

Cognitive Skills - The student should be able to:

1. Take a thorough history and perform a physical examination directed toward specific problems within the given specialty.
2. Use information from the history and physical examination to formulate a differential diagnosis.
3. Integrate information from diagnostic studies in medical problem solving.
4. Begin to formulate an appropriate management plan.
5. Recognize what information from the medical record should accompany the patient being referred to a specialist.
6. Recognize what information is used to determine when a referral to a specialist is needed.
7. Recognize what information from the specialist's evaluation should be transmitted back to the primary care provider.
8. Enter information appropriately in the medical record.
9. Interpret laboratory tests commonly used in that specialty.
10. Present a case to other medical professionals.
11. Write prescriptions under supervision.
12. Behave in a professional manner and relate well with patients, patients' families and other members of the health care team.

Didactic Knowledge - The student should be able to:

1. Describe for patients of various ages the clinical presentation, pathophysiology, appropriate application of diagnostic tests and management of chronic adult health conditions within that specialty.
2. Be able to describe the acute and chronic aspects of diseases commonly seen in that subspecialty.

Subspecialty Surgery Rotation Objectives:

Upon completion of the surgical experience, the student will have:

1. An understanding of the relationship between the primary care provider and the surgeon.

• What information is used to determine whether a referral to a surgeon is needed?
• What information from the medical record should accompany the patient being referred to a surgeon?
• What information from the specialist's evaluation should be transmitted back to the primary care provider?

2. Taken a thorough history and performed a physical examination on a surgical patient.
3. Interpreted clinical findings logically and concisely, to arrive at a surgical diagnosis and management plan.
4. Been introduced to the continuum of preoperative to operative to postoperative care.
5. Knowledge of the positive and negative factors influencing convalescence and rehabilitation.
6. Behaved in a professional manner and related well with patients, patients' families, and other members of the health care team.
7. Obtained the following surgical skills:

• Utilize sterile technique
• Perform a surgical hand scrub
• Administer office/local anesthesia
• Suture skin
• Staple skin

Subspecialty OB/GYN Rotation Objectives:

Upon completion of the OB/GYN experience, the student will have:

1. An understanding of the relationship between the primary care provider and the Obstetrician/ Gynecologist.

• What information is used to determine whether a referral to an OB/GYN specialist is needed?
• What information from the medical record should accompany the patient being referred to an OB/GYN specialist?
• What information from the specialist's evaluation should be transmitted back to the primary care provider?

2. Taken a history from an obstetrical/gynecological patient.
3. Performed a physical examination of the obstetrical/gynecological patient.
4. Used the information from the history and physical examination to formulate a differential diagnosis and begin formulating a management plan.
5. Been introduced to the continuum of prenatal to antenatal to postpartum care.
6. Knowledge of the schedule of wellness gynecological care: mammography, pap smears, self-breast examination, pelvic exams.
7. Knowledge of the pluses and minuses of the different contraceptive options available.
8. Behaved in a professional manner and related well with patients, patients' families and other members of the health care team.