Medical College

Medical College

Training Guide

Clerkship

I.  Introduction:-

A clerkship is an educational exercise that brings the student into personal contact with patients, under close supervision of faculty (trainer).

It is a total emersion experience that involves the student throughout a full working day for the duration of the clerkship.

II.  General Objectives:-

1 / Essential / Demonstrate the ability to take focused history for patients presenting with common medical diseases.
2 / Essential / Demonstrate skills of appropriate physical examination with emphasis on normal and abnormal features on physical examination.
3 / Very desirable / Synthesize the information obtained from history and Physical examination into logical differential diagnosis.
4 / Very desirable / Develop a working management plan.
5 / Desirable / Develop plans for appropriate and cost-effective investigation to reach the diagnosis.
6 / Very desirable / Develop the skills to interpret these investigations.
7 / Very desirable / Demonstrate competencies in basic diagnosis and procedural skills relevant to common medical conditions.
8 / Desirable / Able to select the proper therapy and be aware of its interaction, side effect and complication.
9 / Very desirable / Distinguish medical conditions requiring normal or immediate referral to concerned specialties.
10 / Very desirable / Rapidly recognize medical and trauma emergencies requiring urgent a plan for action.
11 / Very desirable / Demonstrate basic proficiencies in competencies in procedural skills relevant to each specialty.
12 / Desirable / Recognize medical manifestation of diseases.
13 / Very desirable / Maintain ethical attitudes and professional behavior of student during training, concentrating on punctuality, responsibility and teamwork.
14 / Very desirable / Encourage every student to develop his/her steam by analyzing his/her weakness and strengths, during training.
15 / Very desirable / Demonstrate appropriate and affective verbal skills (using language appropriate to the patient "doctor/patient relationship) as well as effective listening skills
16 / Very desirable / Get used to critical thinking and self-learning.

The students should make every effort to perfectly learn and master the following competencies:-

1.  History taking.

2.  Physical examination.

These two competencies are considered of importance to learn at this stage.

Although emphasis on these two does not in any way mean that other competencies should be ignored. They are very desirable to learn,

Other important aspects are punctuality and attendance.

Without attending; learning will not happen!

Not taking this in consideration might affect training outcome.

III.  General:

1.  Dress and badge:

The student must wear respectable dress and the white coat of AlMaarefa College and his/her badge all the time during training.

2.  Required tools and books:

-  Stethoscope

-  Otoscope

-  Reflex hammer

-  Penlight

-  Pocket text

-  Maxwell quick medical reference.

-  Elision’s pocket reference.

-  Hutchison's clinical method

-  Clinical examination 5th Edition

Mason & Swash

3.  Registration / Rules and Regulation:

-  All students must register in the training hospital (Recommended two days before the start of the training).

-  Student must follow the hospital rules and regulations. Any violation of these rules might cause expelling of student from training by the hospital authority.

-  Student must respect too all hospital staff and interact with them professionally.

-  Student must respect confidentiality of patients, staff, files and the training hospital.

-  Taking pictures of hospital sights, patients or staff is forbidden.

4.  Attendance:

Student must attend daily according to the hospital time. Punctuality must be strictly adhered to. Student should know that non-punctuality and absence will certainly affect the overall assessment of clerkship training, and may result in repetition of rotation.

5.  The end of a rotation:

On the last day of rotation, the student should make sure certain tasks are completed as follows:

Department:

-  Return any items borrowed from the department.

-  Obtain the signature of the authorized trainer on the cases/skills log, and evaluation forms.

Hospital:

-  Return any items borrowed from the hospital.

-  Obtain his/her clerkship completion certificate signed by the academic training department.

AlMaarefa College:

-  Submit all the training materials (Case/skills log, the required completed case presentations etc.) To ALMAAREFA College training director.

IV.  Clinical Rotation:-

During rotation in different specialties, the student must fulfill the following responsibilities:

1.  General responsibilities:

a.  Act professionally at all time.

b.  Be punctual and dependable.

c.  Cell phone should not be used during time of consultation or dealing with patients, lectures and teaching sessions.

2.  Specific responsibilities:

a.  Assist in accumulation of lab results and patient’s records.

b.  Deal with patients in a respectful, compassionate, and empathetic manner.

c.  Must be prepared to participate in all educational opportunities.

d.  Keep a log of patients and / or procedures that you have actively attended and followed.

e.  Refrain from idle talk about cases on the wards, conference room, elevator and cafeteria.

f.  Attend morning reports, grand rounds, and any other required activity in the department.

g.  Should be prepared to present patients’ cases and updated follow-ups on rounds and other teaching activities.

3.  Pre clerkship didactic lectures:

This aims to increase students’ medical knowledge (information’s pyramid), before being exposed to practically seeing patients.

The theoretical part is given in the form of lectures, tutorials, group discussions, presentations, and Directed Self Learning (DSL) sessions.

4.  Hospital Rotation

The hospital training may involve ambulatory care settings (outpatient clinics), and/or inpatient settings (bedside teaching). Students will learn some procedures and skills in different specialties, and the rotation might include attending some operative sessions according to specialty.

A.  Progress Note:

SOAP Note:

Students are required to record and follow patients' conditions utilizing the "SOAP" format as follows:

S = Subjective (overnight events, what the patient tells you about how they are feeling). Usually includes brief chief complaints, Brief history of present illness, medication, many include patient past medical, surgical, family and social history.

O = Objective (what you find on vital signs, clinical exam, labs, tests) objective information.

A = Assessment (brief recap the clinical situation in few lines) usual a one-line, run on sentence.

P = Plan (what we are going to do about each and every issue) organized either by system or by problem.

The length and style of a SOAP note varies with each clerkship (shorter note in surgery, longer ones in medicine, and in between in family medicine) but the idea is the same.

B.  Patient Presentation:-

Pre-rounding

Pre-rounding is the time before rounds when a student in clerkship can gather information on patients, including what happened to them overnight and how they are feeling, as well as a focused physical exam. For example, if the team meets at 8 am for morning rounds, most students would arrive at 7 am to perform a pre-round on patients. Pre-round notes do not have to be written by the time rounds start (if possible, better) but the student should have a good general sense of what the patient issues are, and what course of treatment should be pursued so he/she can present the patient to the team during rounds.

Issues to find out while pre-rounding:

-  Vital signs:

Maximum and current temperatures, heart rate, blood pressure, respiratory rate, oxygen saturation, level of pain (scale 0-10) .

-  How the patient felt overnight

-  Labs:

Record any early morning labs that were drawn or lab from previous night and make note of any labs pending.

-  Management:

Look in the chart for any new orders written overnight.

-  Medications:

Look at the medication chart for what the patient received. It is important to make sure that all medications ordered have actually been taken.

-  Input / Output chart:

Whenever appropriate, an input / output balance chart and amounts of drains, urine output, passing wind or bowel motion, etc. should be mentioned

-  Physical Exam:

Perform a patient physical exam

-  The student is expected to present a patient case (at least once) on the patient grand round. Therefore the student must take a full history and full examination of a patient (directed by the hospital trainer before round).

Presenting a patient:

Students should be prepared to present a patient in the morning rounds (at least once during clerkship duration) an effort should be made to make your presentation without the use of notes (personal note are acceptable in early rotation).

Limit presentation to 2 – 4 minutes.

Presenting a patient is one of the important skills of medicine you will learn this year. If you know your patient well enough that you can present to anyone, then you have done half your job already.

Presenting a patient involves:-

-  Explaining the patient’s chief complaints.

-  History of patient illness.

-  Past medical history.

-  Allergies

-  Finding on physical exam.

A general presenting pattern is as follow.

1.  Chief complaint.

2.  Why is the patient here?

3.  Past medical history.

4.  Medications / allergies.

5.  Social and family history.

6.  What has been done since admission?

7.  How the patient did overnight.

8.  Vital signs and physical exam.

9.  Assessment.

10. Plan.

Specialty Rotation:-

The study of medicine after the preparation year, consists of 6 years three of which are basic science and other three years of clinical medicine in the form of hospital rotations (5th, 6th and internship)

The clerkship for the 5th and 6th year compromise different specialty and varies in duration for each. The rotation of each specialty will compromise of theoretical lectures and practical rotations.

Welcoming and orientation:-

In the morning session and after welcoming the students, they will be shown the places of the specialty clinics and deferent facilities and introduced to the department staff.

The students also will be shown the location of the library, cafeteria and the conference room / teaching room.

An overview of the rule and regulations of the institute is given, with emphasis on ethical and professional behavior.

Introduction Tutorials:

The trainer will give students an introductory tutorial(s) that include the following:

1.  Related to Specialty:

-  A brief outline of clinical anatomy related to specialty.

-  A brief introduction to pathophysiology related to specialty.

-  Basic clinical skills of history taking and clinical examination related to specialty

-  An introduction to tools and instruments commonly used in the specialty.

-  A brief outline of common terminology related to the specialty

-  A brief introduction to therapeutic related to specialty

2.  Professionalism

A definition and brief introduction to the subject is given, with special emphasis on ethics, confidentiality, doctor/patient and doctor/staff relationship, communication skills, and hospital rules and regulations.

Directed self-learning:

The trainer will direct students to identify topics that should be reviewed prior to DSL session. Those topics will be discussed on the designated DSL session.

Case Presentation:

In the case presentation session, each student presents a case (in the pattern of “SOAP”). This is followed by a discussion of the presentation and the case.

The trainer will discuss the student's cases /skills log and give the appropriate marks.

Cases/Skills Log:

The student must document frequency of the cases/skills encountered, in the designated form (below) and an overall summary of all encounters and exposures is gathered. Student will make sure that the trainer sign cases/skills forms.

The form will be used one for each clinic attended (i.e more than one form in each specialty rotation).

In the cases/skills space, student will write the diagnosis, skills name respectively. Also student will document the action decided by the treating doctor (whether medication or referral or other management plan).

Though writing everything student encounters, it is important that student only write what he attends, not copied his pears cases/skills forms.

This might cause a problem when trainer discussed with him/her the cases/skills log he/she did not see or encountered.

Students are advised to attend all morning rounds and fully utilize the hospital free time performing clinical or preparatory and reading activities. Students are encouraged to take the initiative of asking and inquiring about things they do not understand fully or need to see and discuss with the tutors.

/ Cases/Skills Log / Level-9 Clerkship
Student Name:-………………………….…. ID: - …………………………
Trainer Name:-……………………………. Clerkship:-………………….. Hospital:-…………………………………. Date: - / / Session Start:-…………………………….
Cases/skills / Action / Plan

End of session time:-………………………………………….. Trainer's sign:-…

5th year clerkship rotations:-

This year consist of two levels, level nine (9) and level ten ( 10).

Level 9 consists of the following:

Family Medicine / ENT
Psychiatry / Ophthalmology
Dermatology

Level 10 consists of the following:

Anesthesia / Orthopedic
Obs/Hyn / Emergency

Family Medicine:-

1.  Course Description:-

Family medicine is now recognized as a specialty based on a body of knowledge and an approach to care unique to its discipline. Because family physician commitment is to the person and not to a particular organ system, age group, or technique, they must be skilled in accepting responsibility for the full scope of care of patients in health and illness at all stages of the life cycle. While facets of this comprehensive patient centered approach are not present in the care provided by others, no other discipline has all of these tenets as its core raison.

This approach is described according to the four principles of family medicine.

1.  The family medicine is a skilled clinician.

2.  The patient physician relationship is central to family physician role.

3.  The family physician is resource to a defined population (catchment area).

4.  Family medicine is community based.

2.  Specific Objectives:

By the end of family medicine clerkship rotation, students will be able to:

1 / Essential / Describe how illness presents differently in the family medicine compared to other specialty setting.
2 / Essential / Demonstrate an approach to the diagnosis and management of undifferentiated patient problems that present to family physician.
3 / Very desirable / Use patient centered record-keeping when caring for patients.
4 / Essential / Able to obtain informed consent appropriate to their level of care.
5 / Very desirable / Able to identify what health-promotion and disease prevention during patient encounters that reflect best evidence and patient preferences and values.
6 / Essential / Identify pharmacotherapeutic approach to primary case conditions based upon the patient’s context and issues such as pharmacodynamics, Pharmacokinetics, adverse effects and important drug interaction.
7 / Very desirable / Have an approach to polypharmacy.
8 / Essential / Understand the family physician’s role in maternity childhood care, palliative care, home health care and other setting in work.
9 / Essential / Appreciate the value of continuity of care for developing a deep knowledge of patients.
10 / Very desirable / Demonstrate application of ethical framework in clinical decision-making process.
11 / Very desirable / Demonstrates a willingness to become involved in the full range of difficulties which patients bring to their physicians and not just their biomedical problems.
12 / Desirable / Demonstrates skills in finding common ground with patients.
13 / Desirable / Encourages patients to take as active a role as they are comfortable with, in collaborating towards decisions on treatment plans.
14 / Very disirable / Demonstrate sensitivity to cultural differences between physicians and patients and encourage patients to help their physician to understand these.
15 / Very desirable / Recognize the important of doctor-patient boundaries and can describe common situations that create a risk for a boundary violation.
16 / Essential / Demonstrate an evidence –based approach to decision making with in a patient centered clinical method.

3.  Family medicine Syllabus: