Primary Care Ambulatory Clerkship

Syllabus - Didactic Curriculum

X.) Didactic Overview

The didactic portion of the experience includes the following:

Current Case Review - The purpose of the current case review experience is to provide the student with the opportunity to develop skills in presenting patient cases and to discuss current and future management of active cases in the ambulatory care setting.

Topical Formal Presentation - The purpose of the topical formal presentation is for students to develop knowledge in a specific primary care area as well as skills in presenting a paper and leading a discussion.

Reading Medical Literature - A Tool for Improving Patient Care - The purpose of this experience is threefold: 1) to improve students' skills in locating, selecting, and critically reviewing medical and lay literature relevant to the practice of primary medicine; 2) to improve students' skills for keeping abreast of new medical information, deciding which of this information is valid and applicable to patient care, and using this information to improve patient care; and 3) to prepare students to participate confidently and effectively in medical journal clubs at their places of training or practice.

Symptom Seminar - The purpose of the symptom seminar is to discuss the most common symptoms presenting in primary care settings.

Procedures - The purpose of this experience is to provide students with skills in common ambulatory care procedures.

Clinical Decision Making and Managed Care - The primary objective of this module is to help equip the student with clinical reasoning skills and practices suitable for the new managed care environment and which are representative of sound medical practice.

Additional Academic Day Activities - Additional experiences in departments highly relevant to primary care, may be identified at your base hospital.

XI.) Current Case Review

Purpose:
The purpose of the current case review experience is to provide the student with the opportunity to develop skills in presenting patient cases and to discuss current and future management of active cases in the ambulatory care setting.

Objectives:
The student will:

  1. Develop the skills to present patient cases in a succinct and logical manner that include pertinent positive and negatives in the following areas:
  • chief complaint and history of presenting illness
  • past history
  • family and social history
  • review of systems
  • physical examination
  • laboratory and radiological data
  1. Identify and prioritize problems appropriately.
  2. Include all appropriate possibilities in the differential diagnosis with related rationale.
  3. Develop a management plan individualized to the patient that reflects knowledge of osteopathic principles.
  4. Identify research/theories from the biological, behavioral and community sciences that are guiding your practice.
  5. Identify legal and ethical issues related to the case.

Format:
Week 1 of this experience will be spent discussing "How to Present a Case." Starting week 2, students need to be prepared weekly to present current cases they are managing in their ambulatory care settings. Presentations should address those areas outlined in the objectives. Presentations will be followed by discussion of the case in the group.

XII.) Symptom Seminar

Purpose:
The purpose of the symptom seminar is to discuss the most common symptoms presenting in primary care settings. Discussion will cut across age groups and systems and have an osteopathic or holistic approach.

Objectives:
The student will:

  1. Develop data gathering skills.
  2. Develop differential diagnosis skills in relation to common primary care symptoms.

Format:
Faculty will distribute a bibliography one week in advance. The format for the sessions will be presentation of minimal subjective data similar to that which would be available for a clinic/office visit. Students will then generate further data to be gathered and go through the clinical decision making process.

Symptoms to be Discussed:

  • Fever
  • Skin Rash
  • Abdominal Pain
  • ENT symptomatology (rhinorrhea, sore throat, earache, etc.)
  • Chest Pain/SOB
  • Diarrhea/Constipation
  • Tiredness/Exhaustion
  • Headache
  • Joint Pain
  • Cough & Wheezing
  • Anxiety/Depression

XIII.) Topical Formal Presentation

Purpose:
The purpose of the topical formal presentation is for students to develop knowledge in a specific primary care area as well as skills in presenting a paper and leading a discussion.

Objectives:

  1. Advance their knowledge and skills in relevant primary care topic areas.
  2. Develop the skills to organize and present a paper that is multidimensional and reflects a synthesis of current thinking and research in the topic area.
  3. Demonstrate skills in leading a discussion.

Format:

  1. Students need to select a topic for presentation and work closely with the faculty member for the group and identified content experts developing their presentation. These meetings with faculty need to occur well in advance during development of the presentation.
  2. Students need to distribute select bibliographies one week in advance to be read by everyone prior to the presentation.
  3. Students will do a formal presentation lasting no longer than 30 minutes followed by a group discussion.
  4. Powerpoint needs to be utilized for the presentation.

XIV.) Reading Medical Literature

The material for the Reading Medical Literature segment of PCAC material is available in the Reading Medical Literature folder on the PCAC Angel Group Site.

MSU (East Lansing) Faculty for Reading Medical Literature:

Dr. Robert Stephenson
Physiology
517/884-5057
stephen9@msu.edu

Leslie M. Behm
Libraries
517/884-1953
behm@msu.edu

Additional clinical faculty, as arranged by PCAC office.

For a list of RML faculty for your site, refer to the PCAC Coordinators under PCAC Sites

Purpose:
"Reading the Medical Literature: A Tool for Improving Patient Care" consists of a series of lessons and practice sessions designed to:

  1. Improve students' skills in locating, selecting, and critically reviewing medical and popular media reports relevant to the practice of primary medicine.
  2. Improve students' skills for:
  • Keeping abreast of new medical information
  • Deciding which of this information is valid and applicable to patient care
  • Using this information to improve patient care
  1. Prepare students to participate confidently and effectively in medical journal clubs at their places of training or practice.

Note that "Reading Medical Literature" is NOT designed to teach students specific clinical knowledge. Instead, the emphasis is on reviewing the concepts and practicing the skills necessary for accessing, reading, and evaluation of medical literature and its application to patient care. These concepts and skills are essential foundations for each student's continuing self-education throughout his/her whole professional career.

Overall Goals and Objectives:
The student will be able to:

  1. Identify and distinguish between various types of medical literature (original study, review, meta-analysis, etc).
  2. Identify and distinguish between various types of medical studies (case-series, cohort, case-control study, etc).
  3. Utilize computerized medical databases to conduct focused literature searches, making appropriate use of controlled vocabulary and filters.
  4. Do a cursory review of a medical journal article (in about 5 minutes) to determine its major features, including working hypothesis, type of study, objective (conditional prediction to be tested), main results, conclusions, and applicability to the student's clinical practice.
  5. Utilize basic concepts of epidemiology, statistics, and hypothesis testing to understand and critically evaluate a medical study.
  6. Identify the sources of ambiguity in medical research, diagnostic screening and testing, and in differential diagnosis, and distinguish between ambiguity that can be remedied and that which is unavoidable (inherent).
  7. Understand how clinical standards of care and practice guidelines are developed and modified.
  8. Participate in the critical analysis of original medical literature in a journal club setting.
  9. Select, prepare, and present a medical paper in a journal club setting and lead the journal club participants in a critical analysis of the paper.

Format:
"Reading Medical Literature" is organized around weekly sessions (90-120 minutes) where students and faculty meet together in a journal club format to discuss and critically analyze papers chosen and presented, initially, by the faculty and then by individual students.

Students are encouraged to review their material from their Biostatistics and Epidemiology course (OST 531).

When possible, each student will also use the medical literature to search out an answer to a question that patients have asked. These answers will then be presented and discussed in a group session.

In summary, the basic sequence for the "Reading Medical Literature" is:

Self-directed Review (Independent Study)
Read the paper to be discussed at the group meeting: faculty-led critique of paper. Prepare and submit a "Quick and Dirty Review" worksheet on paper this paper. The worksheet is in the RML folder of the PCAC Group Site on Angel.
Group meeting: Faculty-led Critique of Paper
Group meetings: Student-led Critiques of Papers and Student responses to "Questions Patients Ask."


A specific schedule for group sessions, including individual student assignments, will be distributed at each clerkship site, in advance of the first session.

Students are encouraged to contact the RML faculty with any questions while preparing for their paper presentation.

Evaluation:
Each student's performance will be evaluated in each of the following areas:

  1. Prompt attendance at group sessions.
  2. Selection and presentation of a journal paper according to specified protocol.
  3. When assigned, the use of relevant medical literature to develop a valid answer to a question that a patient has asked.
  4. Preparation for and participation in the group sessions (journal club sessions) when other students or faculty members are the primary presenters.
  5. Evidence of mastery of goals and objectives.

A satisfactory demonstration of mastery in each of these areas is required for a passing mark on this segment of the clerkship. Remediation of unsatisfactory performance will be at the discretion of the PCAC Coordinator.

XV.) Protocol for Student-Led Critique of Papers


Protocol is in the Reading Medical Literature folder of the PCAC Group Site on Angel. Students are expected to read and then adhere to this protocol.

XVI.) Clinical Decision Making and Managed Care

The primary objective of the managed care module is to help equip students with clinical reasoning skills and practices suitable for the new managed care environment and which are representative of sound medical practice. These skills include:

  • A focus on disease prevention and health promotion.
  • Good history taking and physical examination skills.
  • Understanding clinical epidemiology.
  • Sound clinical decision making based on accurate scientific knowledge of pathophysiology and evidence-based medicine.
  • Practicing cost-effective care.

Other objectives of this module are to increase the delivery of standardized curriculum throughout MSUCOM's Statewide Campus System and to facilitate the integration of appropriate computer-mediated instruction, including accessing the Internet, into the college curriculum and into your practice of osteopathic medicine.

The curriculum has the following components:

  • Module 1: The Role of the Physician in the Interface of Primary and Managed Care
  • Module 2: Clinical Decision Making in Managed Care and Orientation to CD-ROM Cases
  • Modules 3-5: Self-Directed Learning Using Computerized Case Simulations
  • Module 6: Review of Computerized Cases and Student Medical Decision Making

XVII.) Procedures and Skills

The purpose of this experience is to provide students with skills in common ambulatory care procedures.

Basic Radiology
The student will have knowledge of:

  1. When to order radiological examinations.
  2. Which radiological examination to order.
  3. How to approach a radiological examination.

Draping and Sterile Technique and Suturing
The student will:

  1. Learn how to do a sterile prep and drape for minor surgical procedures.
  2. Be able to utilize a needle holder & suture forceps.
  3. Be versed in the proper application of basic suture technique.

EKG Lab
The student will:

  1. Have knowledge of the indications for ordering an EKG.
  2. Know the options and limitations for reading EKGs.
  3. Discuss issues related to EKGs:
  • relevance of cardiac risk factors
  • use as a screening tool prior to general anesthesia
  • HMO vs. private practice
  • economics of EKGs
  1. Analyze some of the more common EKGs presenting in the primary care setting and discuss the related management issues.

Laboratory

Throat Culture
The student will be able to obtain a throat culture utilizing proper technique and be familiar with the different results.

Gram Stain
Presented with a series of slides, a student will:

  1. Review preparation and staining techniques for a smear.
  2. Identify leukocytes (PMNL and macrophage).
  3. Identify bacteria as gram positive and negative, and as rods or cocci.

Fecal Occult Blood Testing
The student will be familiar with how to test for occult blood on a stool specimen.

Wet Prep
Given a specimen of vaginal secretions, the student is able to observe/evaluate:

  1. Proper preparation of the sample using saline and KOH.
  2. Identify normal flora, yeast, trichomonas and "clue" cells.

Venipuncture
The student will be given an overview of venipuncture techniques; tube anticoagulants; and, techniques for collecting blood cultures, ABGs, and Allen test clotting vs. hemolysis.

CBC/Urinalysis

CBC
Given a peripheral blood smear, the student understands how to, or is able to:

  1. Comment appropriately on RBC morphology.
  2. Identify PMNLs, eosinophils, monocytes and lymphocytes.
  3. Determine how each of the values on the CBC report is determined.

Urinalysis
The student will understand a complete urinalysis, including:

  1. Review of urine specific gravity.
  2. Review of chemical tests for pH, protein, glucose, blood, and ketones.
  3. Review of appropriate techniques for centrifugation and preparation of a slide for microscopic analysis.
  4. Identification of WBCs, RBCs, and bacteria.
  5. Recognition of casts when present.
  6. Review of urine pregnancy tests, including a demonstration of a positive and a negative test

Medical Informatics Exercises
The student will:

  1. Be able to answer clinical questions utilizing the internet.
  2. Understand how the use of medical informatics can enhance the practice of medicine.

Prescription Writing
The student will be able to:

  1. Calculate pediatric doses.
  2. Write prescriptions efficiently and accurately.
  3. Describe the practical aspects of the Controlled Substance Law.
  4. Locate needed information about drugs efficiently.
  5. Consider the issue of relative cost where appropriate.

Pulmonary Function Study Interpretation
The student will have knowledge of:

  1. When to order office spirometry.
  2. What information they can expect from office spirometry.
  3. How to perform and interpret office spirometry.
  4. How to use this information for therapeutic decision-making with patients with airway disease.

Splinting and Casting
The student will have knowledge of:

  1. Fracture management: what do you cast? what do you splint?
  2. When you should refer to an orthopedic surgeon.
  3. How to properly apply a splint and a cast.