FAMILY MEDICINE CLERKSHIP SYLLABUS

UNIVERSITY OF LOUISVILLE

DEPARTMENT OF FAMILY AND GERIATRIC MEDICINE

SCHOOL OF MEDICINE

2013-2014

Donna M. Roberts, M.D.

Course Director 852-5314

Jeri R. Reid, M.D.

Associate Course Director 852-5314

Anne Loop

Project Coordinator 852-5314

Fax-852-7142

Lana Metzler

Placements Coordinator 852-2707

DFGM Main Office for emergencies only

852-5201

Syllabus prepared by Donna M. Roberts, MD, last updated June 13, 2013

Schedule/information presented in syllabus is subject to change. Students will be notified by RedMed Website and by Outlook email of changes.

Credit Hours = 7.5 Prerequisite: Third Year Status

TABLE OF CONTENTS

I. WELCOME......

II. INTRODUCTION......

AHEC......

III. EDUCATIONAL GOALS......

IV. LEARNING OBJECTIVES......

Principles of Family Medicine......

Clinical Experiences......

Table 1: Core Acute Presentations......

Table 2: Core Chronic Disease Presentations......

V. COURSE RESPONSIBILITES

A. Clinical Experiences......

B. SOAP Notes......

C. Independent Learning Activities......

C. Group Learning Activities......

VI. ASSESSMENT...... 15

A. Mid-Clerkship Feedback...... 15

B. fmCases Quiz......

C. Final Exam......

D. Clinical Evaluations...... 16

E. Grading......

F. Honors......

VII. COURSE REQUIRMENTS...... 17

A. Evaluation...... 17

B. Patient Logs......

C. Attendance......

D. Assignments Checklist...... 18

VIII. LEARNING RESOURCES...... 20

A. REDMED...... 20

B. TEGRITY LECTURES......

C. ACCESSING REDMED

D. TEXT......

IV. ADDITIONAL GUIDELINES FOR STUDENTS...... 20

A. DRESS CODE...... 20

B. EMAIL AND CONTACT METHOD...... 21

CLERKSHIP LOCATIONS...... 21

APPENDIX 1: CLINICAL AND TEACHING OPPORTUNITIES...... 22

APPENDIX 2 – OME POLICIES...... 23

I. WELCOME

Welcome to the Family Medicine Clerkship. This six-week rotation will enable medical students to understand the principles of family medicine and their application in community practice. Family Medicine, the one medical specialty that provides continuing and comprehensive medical care for individuals and families, integrates the biological, clinical and behavioral sciences in the care of the undifferentiated patient. Family Medicine differs from other specialties in that it encompasses all ages, both-genders, each organ system and every disease entity. Family Medicine provides first contact, ongoing, and preventive care. Family medicine clinical experiences allow students to understand how context influences the diagnostic process and management decisions. Students learn the fundamentals of an approach to the evaluation and management of frequently occurring, complex, concurrent, and ill-defined problems across a wide variety of acute and chronic presentations.

II. INTRODUCTION

Most of the students’ time in the clerkship will be spent caring for patients in ambulatory settings although students will have opportunities to work with physicians in the care of their hospital and nursing home patients. The clerkship places students with family physicians in approved AHEC locations throughout Kentucky. Students will also work with faculty and residents at residency training sites for the Department of Family and Geriatric Medicine (DFGM). Students will observe the family physician’s interactions with sub-specialists and use of allied health professionals. The students will gain an appreciation of different skills required to manage patients in the outpatient setting and in the context of the family unit.

Students will spend four weeks of the clerkship in a medically underserved area of Kentucky working with a family physician under the AHEC guidelines. The other two weeks will be spent in Clinical sitesworking with faculty and residents from the DFGM.

AHEC

The School of Medicine and the Department of Family and Geriatric Medicine are committed to providing medical training in areas away from the University Medical Center setting in conjunction with the Area Health Education Center Program (AHEC). This is a federal and state funded program. AHEC sites include offices of family physicians throughout the state of Kentucky. These physicians have gratis faculty appointments with the Department of Family and Geriatric Medicine.

The Department of Family and Geriatric Medicine will place approximately 100 percent of its students in AHEC areas for the 2013-2014 academic year. Through experiencing medicine in communities throughout Kentucky, students will be able to more fully understand the role played by the Family Physician and other health care professionals in patient management.

Students may receive a stipend to offset the cost of housing while at the AHEC site. If the student receives a stipend it must be turned over to the housing host before the rotation is completed. This check will be mailed from the University of Louisville controller’s office to the student’s permanent address or electronically deposited.

Learning resources

Students will utilize the following resources to meet the learning objectives of the family medicine clerkship.

  • Direct patient care in clinical settings
  • Power Point Presentations on Tegrity
  • Fm Cases
  • Recommended Textbooks:

Sloane PD. Essentials of family medicine. 6th ed. Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins; 2011.

Lipsky MS, King MS. Blueprints family medicine. 3rd ed. Malden, Mass.: Blackwell; 2010.

Toy EC, Briscoe DA, Britton B. Case files. Family medicine. 3rd ed. New York: McGraw-Hill Medical; 2012.

A variety of assessment methods will be used to evaluate the student’s knowledge and skills. These include direct observation using the clinical evaluation forms and the standardized patient cases, the test on fm cases, and the NBME subject exam.

III. EDUCATIONAL GOALS& Alignment with sOM PROGRAM OBJECTIVES

The numeric references below refer to SOM program objectives. A list of the SOM program objectives can be found here:

At the end of the Family medicine clerkship, each student should be able to:

  • Discuss the principles of family medicine.[1.1], [1.7]
  • Gather information, formulate differential diagnoses, and propose plans for the initial evaluation and management of patients with common presentations. [2.1 - 2.6], [3.1], [3.2], [3.5], [4.1], [4.2], [5.1]
  • Manage follow-up visits with patients having one or more common chronic diseases. [4.3], [4.4], [4.5], [5.2], [5.4], [6.9], [7.5]
  • Develop evidence-based health promotion/disease prevention plans for patients of any age or gender.[2.4], [8.5]
  • Demonstrate competency in advanced elicitation of history, communication, physical examination and critical thinking skills.[4.1], [5.1], [6.1], [6.4]
  • Write SOAP notes and give oral presentations in the appropriate format for the outpatient setting.[5.2], [6.2], [6.3]
  • Participate in a community project to demonstrate greater knowledge of the AHEC community.[8.1], [8.3],[8.4]
  • Utilize appropriate techniques to communicate with patients of all levels of health literacy.[6.1], [6.4], [6.9]
  • Demonstrate a commitment to professionalism and continuous improvement. [1.2], [1.9], [1.10], [6.8]

IV. LEARNING OBJECTIVES--SEE SEPARATE REDMED FOLDER

The learning objectives for this clerkship are modified from the Society of Teachers of Family Medicine (STFM) Clerkship Curriculum Document developed by family medicine educators in 2009.

Principles of Family Medicine

Specific learning objectives have been developed that illustrate each of the five principles of family medicine: the biopyschosocial model, comprehensive care, continuity of care, contextual care, and coordination/ complexity of care.

  1. The Biopsychosocial Model - Patient-centered care that approaches patients with sensitivity and responsiveness to culture, age, gender, and disabilities and incorporates psychosocial, cultural and family data into management plans. At the end of the clerkship students should be able to:
  1. Demonstrate active listening skills and empathy for patients.
  2. Demonstrate the ability to elicit and attend to patients’ specific concerns.
  3. Explain history, physical exam and test results in a manner that the patient can understand.
  4. Use effective listening skills and empathy to improve patient adherence to medication and lifestyle changes.
  5. Discuss the influence of psychosocial factors on a patient’s ability to provide a history and carry out a treatment plan.
  6. Discuss mechanisms to improve adherence to and understanding of screening recommendations.
  7. Use the teachback method to enhance patient understanding.
  8. Provide patient education tools taking into account literacy and cultural factors.
  1. Comprehensive care - Care that attends to the acute, chronic, and preventive needs of patients and families in all phases of the life cycle. At the end of the clerkship the student should be able to:
  1. Formulate clinical questions important to patient management and conduct an appropriate literature search to answer clinical questions.
  2. Find and use high quality Internet sites as resources for use in caring for patients with core conditions.
  1. Continuity of care – The promotion of continuous healing relationships by providing a personal medical home for patients and their families that facilitates ongoing care and access to appropriate consultants and providers. At the end of the clerkship the student should be able to:
  1. Describe the barriers to access and utilizing health care that stem from personal barriers.
  1. Contextual care - The development of treatment plans that are evidence-based and improve functional outcome and quality of life for patients. At the end of the clerkship the student should be able to:
  1. Demonstrate interpersonal and communication skills that result in effective information exchange between patients of all ages and their families
  2. Demonstrate the above skills that result in effective information exchange between patients and other healthcare providers.
  3. Communicate effectively with patients and families from diverse cultural backgrounds.
  4. Discuss areas where culture can impact the ability of patients to access and utilize health care.
  1. Coordination/complexity of care - The integration of complex care and the collaboration with other professionals that results in disease management, health promotion and patient education. At the end of the clerkship the student should be able to:
  1. Describe the value of teamwork in the care of primary care patients.
  2. Participate as an effective member of a clinical care team.

Clinical Experiences

In addition to the key principles of family medicine, there are several unique characteristics of family physicians that provide additional learning experiences for students. Family physicians usually have prior knowledge of their patients that allows for diagnostic testing and treatment to occur in stages that allows for more cost-effective and thoughtful care. Community-based physicians can take into account the prevalence of a disease in the outpatient setting to determine the appropriate course of action. Lastly, many family physicians use acute visits as opportunities to address chronic disease or health promotion issues. All students can benefit from learning how to provide care within this context.

  1. Acute Presentations – The core acute presentations are listed in Table 1. At the end of the clerkship the student should be able to:
  1. Differentiate among common etiologies based on presenting symptom.
  2. Recognize “don’t miss” conditions that may present with a particular symptom.
  3. Elicit a focused history and perform a focused physical examination.
  4. Discuss the importance of a cost-effective approach to the diagnostic work-up.
  5. Describe the initial management of common and dangerous diagnoses that present with a particular symptom.
  1. Chronic Presentations - The general approach to most chronic diseases includes diagnosis, surveillance, treatment, and shared goal-setting. Chronic disease management involves empowering patients to engage in their own care and work as a team member along with their health care professionals. Continuity with patients, provided in the family medicine setting, increases efficacy and improves outcomes. The core chronic diseases are listed in Table 2. At the end of the clerkship, for each chronic disease, the student should be able to:
  1. Find and apply diagnostic criteria.
  2. Find and apply surveillance strategies.
  3. Elicit a focused history that includes information about adherence, self-management, and barriers to care.
  4. Perform a focused physical examination that includes identification of complications.
  5. Assess improvement or progression of the disease.
  6. Propose an evidence-based treatment plan.
  7. Outline the role of nutrition in the management of chronic disease
  8. Document a chronic care visit.
  9. Communicate respectfully with patients who do not fully adhere to their treatment plan.
  10. Educate the patient about an aspect of their disease using the teach-back method.
  1. Health Promotion and Disease Prevention – Family physicians provide preventive care during health promotion visits, during office visits for another purpose, and outside the office in other health care settings. It is important that preventive care be evidence-based, individualized to each patient depending on risk factors, current diseases, patient/parent preference and affordability. Attention to preventive care issues can be included in every office visit. At the end of the clerkship the student should be able to:
  1. Define primary, secondary, and tertiary prevention.
  2. Identify risks for specific illnesses that affect screening and treatment strategies.
  3. For women: elicit a full menstrual, gynecological, and obstetrical history.
  4. For men: identify issues and risks to sexual function and prostate health.
  5. For children and adolescents: elicit appropriate history to include immunization status, developmental milestones, and health risks.
  6. Find and apply the current guidelines for adult, adolescent and child immunizations.
  7. Provide appropriate anticipatory guidance to patient/parent.
  8. Communicate effectively with adults, children, teens and families.

Table 1: Core Acute Presentations

Topic / Common / Serious / Topic-specific Objectives
Upper respiratory symptoms / Infectious: Viral URI, bacterial sinusitis, strep pharyngitis, otitis media, mononucleosis.
Noninfectious: Allergic rhinitis / Epiglottitis / -Recognize that most symptoms are caused by viruses and don’t require antibiotics.
-Determine patient’s pretest probability for strep pharyngitis and make appropriate treatment decision
Joint pain and injury / -Ankle sprains and fractures
-Knee ligament and meniscal injuries
-Shoulder dislocations and rotator cuff injuries
-Hip pain
-Carpal tunnel syndrome
-Osteoarthritis
-Overuse syndromes
(Achilles’ tendonitis, patellofemoral syndrome, subacromial bursitis, rotator cuff tendinosis) / -Septic arthritis
-Acute compartment syndrome
-Vascular compromise associated with fracture or dislocation / -Perform an appropriate musculoskeletal examination
-Apply Ottawa decision rules to determine the need for knee and ankle radiographs
Pregnancy (Initial presentation) / -Intrauterine pregnancy / -Ectopic pregnancy
-Miscarriage / -Recognize common presentations of pregnancy, including positive home pregnancy test, missed/late periods, and abnormal vaginal bleeding
-List recommended lab testing for routine prenatal care.
Abdominal pain / -Gastroesophageal reflux disease
-Gastritis
-Gastroenteritis
-Irritable bowel syndrome
-Dyspepsia
-Constipation
-Functional / -Appendicitis
-Diverticulitis
-Cholecystitis
-Inflammatory bowel disease
-Ectopic pregnancy
-Peptic ulcer disease / -Recognize the need for emergent versus non-urgent management for varying etiologies of abdominal pain
Common skin lesions / -Actinic keratosis
-Seborrheic keratosis
-Keratoacanthoma
-Squamous cell carcinoma
-Basal cell carcinoma
-Warts
-Inclusion cysts / -Melanoma / -Describe a skin lesion using appropriate medical terminology
-Identify skin lesions from photographs and brief clinical descriptors
Common skin rashes / -Atopic dermatitis
-Contact dermatitis
-Scabies
-Seborrheic dermatitis
-Urticaria / Stevens-Johnson syndrome / -Describe the characteristics of a rash
-Identify rashes from photographs and brief clinical descriptors
Abnormal vaginal bleeding / -Anovulatory cycles
-Polycystic ovarian syndrome
-Perimenopausal/menopausal
-Contraception effects / -Miscarriage / -Elicit an accurate menstrual history
-Recognize when vaginal bleeding is abnormal
Low back pain / -Muscle strain
-Altered body mechanics
-Nerve root compression / -Abdominal aneurysm rupture
-Acute fracture
-Spinal cord compromise
-Bone metastases / -Describe indications for plain radiographs for back pain
-Conduct an appropriate musculoskeletal and focused neurological exam for back pain
Cough / -Infectious: Pneumonia, bronchitis, URI, sinusitis
-Nonifectious: Asthma, GERD, allergic rhinitis / -Lung cancer
-Pneumonia
-Tuberculosis / -Describe the indications for chest Xray
-Recognize pneumonia on a chest Xray
Chest pain / -Gastrointestinal
-Musculoskeletal
-Cardiac
-Pulmonary / -Acute coronary syndrome
-Pulmonary embolism
-Pneumothorax / -Recognize the indications for emergent vs. urgent vs. non-urgent management for chest pin
-Recognize cardiac ischemia and injury on an electrocardiogram
Headache / -Tension
-Migraine
-Sinus pressure / -Meningitis
-Subarachnoid hemorrhage
-Temporal arteritis / -Determine when imaging is indicated
Vaginal discharge / -Bacterial vaginosis
-Vaginal candidiasis
-Trichamoniasis
-Cervicitis / -Pelvic inflammatory disease / Evaluate vaginal discharge: wet prep/KOH, pH, whiff test
Dysuria / -Urethritis
-Bacterial cystitis
-Pyelonephritis
-Prostatitis
-Vaginitis/cervicitis / -Interpret a urinalysis
Dizziness / -Benign positional vertigo
-Labyrinthitis
-Orthostatic dizziness / -Cerebrovascular disease
-Brian tumor
-Meniere’s disease
Shortness of breath/ wheezing / -Asthma
-Chronic obstructive pulmonary disease
-Congestive heart failure
-Angina
-Obesity / -Acute exacerbations of asthma or COPD
-Pulmonary embolism
-Pulmonary edema
-pneumothorax
-Acute coronary syndrome / -Recognize typical radiographic findings of COPD and CHF
Fever / -Viral URI
-Strep pharyngitis
-Influenza
-Otitis media / -Meningitis
-Sepsis
-Fever in the immunosuppressed patient / -Describe a focused approach to diagnostic testing in patients with fever in all age groups
Depression (Initial presentation) / Depression / -Suicidal ideation / -Use a validated screening tool for depression
-Assess suicidal ideation and/or substance abuse
Male urinary symptoms/prostate / -Urethritis
-Prostatitis
BPH
Erectile dysfunction / Prostate carcinoma / -Select appropriate laboratory tests for a male patient with urinary complaints
Dementia / Dementia
Delerium / -Perform a validated screening test for cognitive decline
-Select appropriate diagnostic tests for a patient presenting with memory loss, focusing on treatable causes
Leg swelling / -Venous stasis
-Medication-related edema / -Deep venous thrombosis
-Congestive heart failure / -Recognize the need for urgent vs. nonurgent evaluation of leg swelling

Table 2: Core Chronic Disease Presentations

Topic / Topic-specific Objectives
Multiple chronic illnesses / - Assess status of multiple diseases in a single visit.
- List important criteria to consider when prioritizing next steps for management of patients with multiple uncontrolled chronic diseases.
- Document an encounter with a patient who has multiple chronic diseases using a SOAP note and/or chronic disease flow sheet or template.
Hypertension / - Take an accurate manual blood pressure.
- Recognize the signs/symptoms of end-organ disease.
Type 2 diabetes mellitus / - Perform a diabetic foot examination.
- Document an encounter using a diabetes mellitus flow sheet or template.
Asthma/chronic obstructive pulmonary disease (COPD) / -Discuss the differences between asthma and COPD, including pathophysiology, clinical findings, and treatments.
-Recognize an obstructive pattern on pulmonary function tests.
- Discuss smoking cessation.
Hyperlipidemia / -Determine a patient’s cholesterol goals based on current guidelines and the individual’s risk factors.
-Interpret lipid laboratory measurements
Anxiety / -Describe how an anxiety disorder can compromise the ability for self care, to function in society, and to cope effectively with other health problems.
Arthritis / -Guide a patient in setting goals for realistic control of pain and maximize function.
Chronic back pain / -Obtain a medication use history.
- Anticipate the risk of narcotic-related adverse outcomes.
-Guide a patient in setting goals for pain control and function.
Coronary artery disease / - Identify risk factors for coronary artery disease.
- Use an evidence-based tool to calculate a patient’s coronary artery disease risk.
- Counsel patients on strategies to reduce their cardiovascular risks.
Obesity / -Obtain a dietary history.
- Collaborate with a patient to set a specific and appropriate weight loss goal.
Heart failure (HF) / - Recognize the signs/symptoms of HF.
- Recognize signs of HF on a chest radiograph.
Depression (previously diagnosed) / -Assess suicide risk.
- Describe the impact of depression on a patient’s ability for self care, function in society, and management of other health problems.
Osteoporosis/osteopenia / -Recommend preventive measures
Substance use, dependence, and abuse / -Obtain an accurate substance use history in a manner that enhances the student-patient relationship.
-Differentiate among substance use, misuse, abuse, and dependence.
- Communicate respectfully with all patients about their substance abuse.
-Counsel a patient about tobacco cessation
Thyroid disorders / Outline management plan for hypothyroidism. Outline evaluation of hyperthyroidism and thyroid nodules

Students will acquire knowledge of the diagnosis and management of the acute and chronic illnesses through direct patient care and the use of the online fm Cases. Additional topics are covered in short Tegrity lectures on RedMed.