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FAPR 3005: Family & Community Medicine Clerkship 2007-2008
Clerkship Goals and Objectives
After the Family Medicine Clerkship, a student should have a solid understanding of the principles, philosophy, and practice of Family Medicine, including the importance of comprehensive, continuous, and cost effective relationship-centered care.
Goals
- Learn clinical application of principles of prevention.
- Diagnose and manage medical problems commonly seen in ambulatory care settings.
- Gain experience in clinical problem solving in the undifferentiated patient.
- Obtain experiences in medical decision-making in the ambulatory primary care setting.
- Hone history, physical and medical decision-making skills.
- Understand various settings in which Family Physicians practice.
Objectives
- Take a focused medical history and perform a focused physical examination, including family and psychosocial history on 3-4 patients per half day clinical session.
- Order and interpret results of common laboratory tests and radiographic studies.
- Develop a differential diagnosis and formulate a basic management plan for 3-4 patients in each half-day clinical session.
- Demonstrate professional behavior by working as a team member and completing all duties assigned in a thorough, conscientious and dependable manner.
- Understand indications of common screening tests and be able to apply those recommendations to patients in clinical practice.
Clerkship Organization and Student Responsibilities
The clerkship is organized at two levels, the clerkship administrative office and the clinical site. Students have responsibilities associated with each level as noted below:
- The Clerkship Administrative Office in San Antonio (i.e., the clerkship directors and support staff)
This office is tasked by the dean to coordinate clerkship learning activities with the various site directors and coordinators. Individuals in the dean's office go through this office in the event they must contact a student currently in the family medicine clerkship. Therefore, students must respond to messages or pages from clerkship office personnel promptly. Students must have written approval from the clerkship directors before being absent from any scheduled clerkship or clinical experience. Please do not plan any leave until you have received approval from the clerkship office. If an unanticipated circumstance arises, the student must submit a request for an excused absence before taking leave. Students must notify this office in the event of an emergency (e.g., personal illness or death of a close relative) that prevents them from participating in a clerkship or clinical activity. The clerkship office is accountable for the whereabouts of each student during the clerkship. - The Clinical Site (i.e., the site director and/or coordinator)
The clerkship administrative office in San Antonio delegates the responsibility for scheduling clinical learning experiences to key individual(s) at each site. The clinical site directors and/or coordinators locally manage student issues with the guidance of the clerkship administrative office. Both levels of the clerkship communicate frequently to insure a positive learning environment at each site.
Protocol for Contacting Clerkship Leadership
The Clerkship's Coordinator is your first line of contact regarding clerkship issues. The Coordinator will attempt to resolve any of your concerns and requests. If an issue can not be resolved, the next step will be to contact one of the Clerkship faculty, Dr. Kumar or Dr. Schneider. Students are to follow the established protocol to enhance communication and to work with the clerkship's administrative team. Any issue regarding grades should be communicated in writing to the Clerkship Coordinator to be considered by the course committee. See "Request for Grade Review" below.
Learning Activities
Clinical Experiences in Ambulatory Care Settings:
Core Clinical Experience
You will work with a faculty member or a resident in various ambulatory care clinics and inpatient settings. When you see a patient who needs follow up, try to schedule that patient to return on a day when both you and that physician are in clinic. Some students will also see patients supervised by a volunteer clinical faculty in private practice in the community. You must do more than observe or "shadow" the physician. *NOTE: It is your responsibility to inform the clerkship office if you are only "shadowing" so that we can make sure that you have an active hands-on learning experience.
Clinical Experiences in Inpatient Care Settings:
Each site will provide an inpatient experience differently as appropriate. For those of you in San Antonio (does not include students assigned to the Santa Rosa) who will be able to rank their preference for their inpatient experience, there are three options available:
- Inpatient Service at University Hospital – Mostly adult inpatients (plus any kids admitted by Family Medicine) at University Hospital
- Maternity Inpatient Service at University Hospital – Moms (delivered by Family Medicine) and babies at University Hospital
- Geriatrics Inpatient Service at the Nix – Elderly patients with medical illness, including ICU care)
Prior to the start of your rotation you will be contacted by the clerkship office requesting you to rank the options in order of preference.
Classroom Didactics (MANDATORY ATTENDANCE every Friday-see schedule):
The didactic sessions will be held on Friday afternoons. Each student will be expected to report to clinic on Friday morning. After morning clinic, students will attend Family Medicine Grand Rounds, beginning at 12:30pm with didactics to follow. San Antonio students will attend on the main campus in the Medical School and McAllen students will attend at the RAHC in Harlingen. Students at sites outside of San Antonio will attend at their assigned didactic site. Students are not permitted to attend didactics at any other remote locations.
For the Friday didactic sessions, students are expected to dress in appropriate professional attire (i.e., no jeans or shorts). Attendance will be closely monitored for both morning and afternoon sessions. As a measure of professionalism, attendance and tardiness will be closely monitored during didactics. Students arriving late will be noted.
Photo Rounds
During the clerkship each student has the opportunity to use a clerkship-issued digital camera to document interesting cases seen in clinic. Those photos are then shared during Photo Rounds, which will be held during two didactic sessions during the rotation. Students who choose to participate in the photo rounds program can earn 5 extra credit points, which will be added onto their final clerkship point accumulation. All students are required to attend Photo Rounds as a part of the clerkship didactic sessions even if a student does not upload photos.
In order to earn the extra credit students must submit a photo and present it to their classmates. Please submit no more than two photos per case. Submissions will be tracked and monitored. Photos are to be uploaded to the online album at http://public.fotki.com/Photorounds/ .
Interactive Dermatology Atlas
The Interactive Dermatology Atlas allows you to interact with a series of online cases, as if you were seeing patients in an office. You can view pictures of lesions, take history and order labs in real time, then check your assessment and treatment against those of the contributing physician. Students are required to complete the Family Medicine Clerkship Cases, Set #1 online through the atlas website: www.dermatlas.net . Students will be tested on five of the cases from Set #1 on the final exam.
Substance Abuse Curriculum
The following three clerkship activities will inform you about and give you experience with addressing substance abuse in ambulatory care settings:
- A didactic session on substance abuse (see didactic schedule).
- The Alpha Home workshop (required for San Antonio-based students only) . The workshop is held at the Medical School during one Friday afternoon of your clerkship (see didactic schedule). You will hear recovering alcoholics/substance abusers from Alpha Home, a residential treatment center, describe how they started abusing substances, interact in small groups with the Alpha Home volunteers and learn more about what role physicians can play in preventing addiction.
- Attend an open Alcoholics Anonymous (AA) meeting (required for all students at all locations). In this activity you will experience how an "open" AA group interacts, so that you can learn the benefits of 12 step programs for patients with alcoholism or other addictions.
Use the following websites to identify a meeting time and location near you:
www.aa.org AA Main website
www.aainsa.org in San Antonio
www.cbiaa.org in Corpus Christi
www.rgvaa.net in McAllen or Harlingen
Required Diagnoses/Procedures and Logging Patient Diagnoses and Procedures
Students are required to see patients with certain diagnoses throughout the course of their rotation. To see the list of procedures, please view the Required Cases document. Students are then required to log all patients seen into the Diagnoses/Procedures section of E*Value. There is a maximum allowance of two diagnoses per patient. If a student does not see a particular case in clinic, those cases highlighted in yellow on the Required Cases document are available to students in Design-A-Case. For information on logging patients into E*Value or utilizing Design-A-Case, please see the E*Value and Design-A-Case instruction sheet.
Learning Resources
Suggested Text
While a number of excellent Family Medicine textbooks are available, the most vital thing you can do to be successful during your clerkship is to read any and all information available to you on the various health conditions you will see in clinic. There are several texts, listed below, that we can suggest that students use:
- Sloane PD, Slatt LM, Ebell MH, Jacques LB (2007). Essentials of Family Medicine, 5th edition. Philadelphia, PA: Lippincott Williams & Wilkins.
- David AK, Taylor RB, Phillips DM, Scherger JE (2003). Fundamentals of Family Medicine, 3rd edition. New York, NY: Springer-Verlag New York, Inc.
- Lipsy MS, King MS (2005). Blueprints Family Medicine, 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins.
- Rakel, RE (2007). Textbook of Family Medicine: Text with CD-ROM, 7th edition. Philadelphia, PA: Saunders.
- American Family Physician: http://www.aafp.org/online/en/home/publications/journals/afp.html
- MD Consult: http://www.mdconsult.com/php/73604361-2/homepage
- UpToDate: http://www.uptodate.com/
- Use your uthscsa email address and check it regularly. Please contact computer triage at 567-2069 if you have forgotten your email address.
- Regularly clean out our mailbox and discard old messages, so your mailbox will continue to receive email messages.
- When you reach your site, find out if there is a public computer with internet access available. Ask your site director/coordinator for assistance if needed.
- If you are unfamiliar or do not regularly use PDAs, computers and/or the internet, see the clerkship office at orientation.
- Mid Clerkship Evaluation
- Attend an open AA meeting.
- Complete Interactive Derm Atlas Family Medicine Clerkship, Case Set #1
- Final Clerkship Evaluation
- Family Medicine Portion – This section of the exam will consist of two timed parts: the PDA portion and the Dermatology portion. This section as a whole will count as 25% of the Final Exam grade.
- NBME Exam – The remaining 75% of the written exam portion will be based on your performance on the NBME Shelf Exam.
- Standardized Patient Exam – This portion will be taken after the above referenced written sections in the Clinical Skills Center (AAB Building, 2nd Floor). The purpose is to test your examination skills, interpersonal interactions, and medical knowledge base. This portion of the exam will be graded on a “Pass/Fail” only basis. Please note: If you fail this portion of the exam, you may potentially fail the Clerkship and be required to re-take the entire Clerkship as a whole or you may be required just to re-take the Standardized Patient Exam portion.
- Submit your "Request for a Grade Review" letter in writing (not email message) to the Clerkship Academic Coordinator (copy the letter to Dr. Lee Jones in Student Affairs) within 30 days of the date on your grade/evaluation letter. The letter should be addressed to Dr. David Schneider, Clerkship Director. In your letter, specifically describe your rationale for requesting a grade review. The clerkship office will acknowledge the receipt of your request in a letter. Do NOT contact the person(s) who awarded you the grade or evaluation you are contesting.
- The clerkship directors will consider your appeal and respond in writing with a letter to you.
- Access patients to obtain a medical history, perform a physical exam and follow the inpatient and/or outpatient course.
- Access the patient's entire medical record, including laboratory reports, x-ray reports, etc.
- Perform appropriately supervised procedures as authorized by the patient's attending physician. For procedures such as drawing blood that the student has been trained for and declared competent in, the student may draw blood and perform independent of direct supervision.
- Perform basic laboratory studies such as urinalysis, under appropriate supervision and review.
- When the student is clinically prepared, write orders for specific patients. All of the orders written by a medical student must be reviewed and countersigned by the responsible resident or attending physician before forwarding to the nursing service.
- Write progress notes that the responsible resident or attending physician must review and countersign before they are placed in the patient's chart.
- Write orders independently, without review and counter-signature by the responsible resident.
- Be the primary line of communication in the critical value reporting process.
- Have sole responsibility for communicating vital patient related information to the patient or family members.
Family & Community Medicine Clerkship Website
All clerkship related items can be found on the Family & Community Medicine Clerkship Website, including didactic related material (handouts, required reading, digital records, etc), Photo Rounds, PDA use, Clinical site information and frequently used forms. http://familymed.uthscsa.edu/education/clerkship/clerkship.htm .
Computer Related Issues
Email, PDAs, computers and the internet are used extensively in the Family Medicine clerkship to enhance communication and the educational experience. Below are a few tips to help you with the technology-related parts of the clerkship.If you have any trouble accessing or using the technology-based parts of the clerkship, contact Jill Stetzer at 210-567-0428 or stetzer@uthscsa.edu.
Assignments Checklist
The assignments that must be completed by students at all locations are listed below:
Check When Completed |
Due Date |
Assignment |
Instructions |
| Week 3, by 4pm on Friday | Green paper form in your clerkship folder. Review form with faculty member, return signed form to clerkship office. | ||
| Week 6, by 4pm on Thursday (*NOTE: You must complete these three assignments prior to taking the FM Final Exam on Friday |
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Find meeting online: |
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| Derm Atlas Website: www.dermatlas.net |
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| An email message will be sent to you on the final Friday at the end of the day containing a web address where you will complete the evaluation online. |
Grade Criteria
Your final clerkship grade consists of two parts: Approximately 60% is from the Clinical Evaluation Average and 40% is from the Final Exam Score. There is an extra credit component in the form of Photo Rounds participation as well. NOTE: Grades are based on point accumulation. Raw scoring is used to calculate point accumulation. There are no percentages utilized.
Based on the grade criteria, below is how the formula for grade determination breaks down:
(FM x 1) + (NMBE x 3) + (Clin_Eval_Avg x 6) + (*5 extra credit points) = Final Grade for Clerkship
*Participation in both sessions of Photo Rounds is required to received extra credit
*The maximum score possible on the Clinical Evaluation is 95 points - (Honors = 9.5; Meets Expectations = 8; Concerns = 6; Unacceptable = 0)
Example:
Family Medicine Portion = 96 |
NBME (raw) Shelf Exam = 72 |
Clinical Evaluation Average = 92 |
(96 x 1) + (72 x 3) + (92 x 6) + (*5 extra credit points) = 871
| Letter Grade | Point Range |
A |
870 and above |
B |
800-869 |
C |
760-799 |
F |
<760 |
Clinical Evaluations
Students are evaluated by faculty physicians and family medicine residents during the clerkship using the Clinical Evaluation form. A copy for you to review to understand the expectations will be placed in your student file that you receive during orientation. Students are encouraged to review the form with their supervising physicians at the start of the rotation to identify performance expectations.
You must receive mid-clerkship evaluation from one of your supervising physicians at the end of the third week to inform you and the clerkship directors if you are meeting expectations. At the end of the Clerkship, Faculty will fill out the Clinical Evaluation on your performance online utilizing the E*Value Evaluation System. All evaluations received will be used in the grading process and no evaluation will count more than another. They will all carry the same weighting in the grading process.
Final Examination
The final exam (three parts) will include testing on the Interactive Derm Atlas cases and PDA proficiency, the NBME Shelf Exam, and the Standardized Patient Exam. The exam tests your ability to apply your knowledge of the common problems and issues that are seen in Family Medicine. Enthusiastic participation in the clinical care of patients, Friday didactic sessions, using your PDA medical software each day in clinic, and diligent reading and studying are the best strategies for doing well on the exam. Students need to load the following software tools on to their PDA and be familiar with Shots 2008, Epocrates or a comparable drug database, Archimedes or a comparable medical calculator, and InfoRetriever. Links to all of these software programs are accessible through the Clerkship PDA Resources website, http://familymed.uthscsa.edu/education/clerkship/pda.htm . *PROFICIENCY WITH ALL THESE PDA TOOLS IS REQUIRED FOR THE FINAL EXAM.
Below is the breakdown on how your Final Exam grade will be determined:
*All students will return to San Antonio to take the Final Exam.
*No portion of the grade information (NBME test results, Family Medicine test results, clinical evaluations, etc.) will be released to the student until grades are finalized and entered into the grade roster.
Professionalism
You are expected to demonstrate a level of competence both academically and professionally. While professionalism and ethics are not directly incorporated into your grades, any demonstration of unprofessional or unethical behavior may result in a reduction of your grade or an inability to pass this course. If a question arises concerning unprofessional or unethical behavior, the course faculty will arrive at a consensus concerning how the behavior will affect your grade over and above the grade determination procedure outlined previously.
Request for Grade Review
Grades are personal and confidential information that will only be discussed with the student (and other persons with the student's written permission and in the student's presence) in the clerkship director's office. Students who wish to request a grade review must follow this procedure:
If you are dissatisfied with the decision, you must follow the procedures as outlined by the Office of Student Affairs.
Guidelines for Clinical Activities by Medical Students
Medical students rotate in clinical settings to learn all aspects of patient care, including obtaining patient histories, performing thorough physical examinations, formulation differential diagnoses, learning to make decisions based on appropriate laboratory and radiological studies and procedures, interpreting results of special studies and treatment, communicating with patients on all aspects of disease and prognosis and communicating with members of the health care team.
To this end, the medical student may participate in the following activities:
Students CANNOT:
Additional Guidelines for Students
Follow All HIPPA Rules
As a member of the healthcare team you must insure patient confidentiality at all times. This means you must only disclose patient information to individuals who are directly caring for a patient. You can also only access/read the charts of patients with whom you have a therapeutic relationship.
Student Schedule Change Requests
Students are required to work 9 half days per week, Monday-Friday. There are no full or half days off. If a student is in clinic at any time other than the normal morning or afternoon hours (except in a voluntary capacity), they must get approval in advance via email from the clerkship coordinator so their daily schedule can be adjusted.
Attendance
You must be on time and present for all clerkship activities. If you must be absent, phone the Clerkship Administrative office (567-0428). If a change occurs in your clerkship schedule (e.g., preceptor is ill), contact the Clerkship Office immediately.
Dress Code
Students must wear a name badge, closed-toe shoes (required by OSHA), and appropriate professional attire at all times. For the Friday didactic sessions, students are expected to dress in appropriate professional attire (i.e., no jeans or shorts).
Email and Pager Use
Students will receive email at their UTHSCSA email address from the clerkship directors and coordinators throughout the clerkship. Check your email regularly for messages. Students must have a functional pager or mobile phone, with the number on record in the clerkship office. You are expected to respond to mobile calls and pages within 15 minutes.
Leave Requests, Unexpected Absences, Emergency Situations and Illnesses
The clerkship directors will consider leave requests for absences due to unexpected or unavoidable situations. All requests for approved absences must be received in writing prior to the start of the clerkship with the date(s) of the requested absence, the reason for the absence, and the activity's location and time (including airline flight information if flying). Do not arrange travel until you have written approval from the clerkship directors.
If an emergency occurs (e.g., auto accident) between 8:00am-5:00pm, Monday-Friday, telephone the clerkship office (210-567-0428) immediately. Do not send an email. Describe the situation to the clerkship coordinator. The coordinator will contact the clerkship director(s). All absences may be required to be made up at the discretion of the course leadership. If an emergency occurs outside of normal working hours, the student is to call or page Dr. Ashok Kumar at (210) 287-3383 cell phone or (210) 235-0416 pager for instructions.
Students must inform the San Antonio clerkship office if they are too ill to participate in clerkship activities. Students who are ill for more than one day must be evaluated by a physician. The physician must write an excuse saying the student cannot participate in clerkship activities for a specific number of days due to an illness. The student must give the clerkship coordinator or site coordinator that written excuse before rejoining the clerkship.
Patient Presentations and Notes
Present each patient you see to an attending or resident. Your notes, though vital for learning and contribute to patient care, cannot be used for billing. So, write notes on a blank continuation sheet and place it in the chart after the completed resident and faculty notes. Ask for feedback on your notes! Write your notes in this problem-oriented (SOAP) format:
Subjective: Provide historical data
Objective: State physical examination and laboratory data
Assessment: Show your thought processes and tell how you arrived at your
diagnosis instead of simply stating the diagnosis.
Plan: List medications, instructions (including patient education), and
follow-up plans. Outline your assessment and plan before talking with
a faculty member or resident.
Chaperones
Use a chaperone when you perform pelvic, female breast, rectal and male genital exams. If you sense that you need a chaperone for a non-intimate exam, ask for help.
APPENDIX A: Clerkship Contact Information
| Administrative Office in San Antonio | ||
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Jill N. Stetzer |
Distributed Education Coordinator | 210-567-0428 |
| Emergency Contact Information | ||
Regardless of clinical site, you may contact any of the following individuals if you have any emergency outside of normal working hours. |
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| F. David Schneider, MD, MSPH | Clerkship Director | 210-235-0416 (pager) |
| Ashok Kumar, MD, FRCS | Associate Clerkship Director | 210-235-3884 (pager) |
| Corpus Christi Family Practice Residency Program | ||
| 2606 Hospital Blvd, 5 West Corpus Christi, Texas 78405 |
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Barbara Estment, MD |
Site Director |
361-902-6570 |
Linda Simmons |
Student Coordinator |
361-902-4621 |
Susan Knotts |
Emergency Contact |
361-902-6762 |
| Diagnostic Pavillion, Leonard J. Paul Family Practice Center | ||
| 4647 Medical Drive San Antonio, Texas 78229 |
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Yvonne Garcia |
Point of Contact | 210-592-0130 |
| 210-592-0490 | ||
| LaMision Family Health Care | ||
19780 Hwy. 281 South |
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Veronica Sosa or Nancy Perez |
Clinic Supervisors | 210-626-3854 |
| McAllen Family Practice Residency Program | ||
| 205 E. Toronto McAllen, Texas 78221 |
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| Suzi Baker | Site Coordinator | 956-687-6155 |
| Yvette Guerreo | Assistant Coordinator | 956-687-6155, ext.7133 |
| Juan Trevino, MD | Site and Program Director | 956-344-8002 |
| CMA North Clinic | ||
| 302 West Rector San Antonio, Texas 78216 |
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Linda Castro |
Executive Assistant |
210-358-0869 |
| Regional Academic Health Center (Harlingen) | ||
2102 Treasure Hills Blvd |
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Angie Bocanegra |
Site Coordinator |
956-365-8814 |
Heath Hale, MD |
Site Director |
956-365-8803 |
| Santa Rosa Family Practic Residency Program | ||
| 333 N. Santa Rosa San Antonio, Texas 78223 |
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Guadalupe Rincon |
Residency Coordinator | 210-704-2575 |
| Southeast Clinic | ||
| 1055 Ada San Antonio, Texas 78223 |
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Donna Rodney |
Senior Administrative Assistant | 210-358-5563 |
| Southwest Clinic | ||
| 2121 SW 36th Street San Antonio, Texas 78237 |
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Maria Leal |
Administrative Secretary | 210-358-5163 |
| University Family Health Center - Downtown (Brady Green) | ||
| 527 N. Leona Street San Antonio, Texas 78207 |
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Thea K. Lyssy, MA |
Assistant Residency Director | 210-358-3937 |