STUDENT EVALUATION

INPATIENT SUBINTERNSHIP IN FAMILY MEDICINE (FPM 441)

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STUDENT NAMEDATES OF ROTATION

PRECEPTOR SIGNATUREPRECEPTOR NAME (PLEASE PRINT CLEARLY)

A. CLINICAL KNOWLEDGE BASE
1. Fund of Knowledge And Understanding of Disease Mechanism Not applicable/not observed
Fund of knowledge and/orunderstanding of disease mechanism may or may not be adequate but demonstrates very poor ability to clinically apply knowledge base. / Has limited overall knowledge base but shows abilities in clinical application, thereby showing significant potential for growth. / Solid fund of knowledge and understanding of disease mechanism with frequent demonstrable ability to apply this understanding in clinical situations. / Outstanding fund of knowledge and understanding of disease mechanism with excellent ability to apply it to clinical situations, and develop and defend differential diagnosis.
B. CLINICAL SKILLS
2. History taking Not applicable/not observed
Extremely disorganized. Consistently lacks focus. Does not obtain psychosocial information. / History with “holes.” Lack of skill in conducting interview. Incomplete problems list. Often poorly focused and missed the forest for the trees. / History thorough, interview technique adequate. Symptom list and pt problem identification adequate and logical, and reflects psychosocial information. / Comprehensive, thorough, precise. Excellent skill in interview technique problem identification and characterization. Consistently able to isolate and focus on key pt problems and integrates psychosocial history well.
3. Physical Exam Not applicable/not observed
Does not conduct appropriate physical exam. Major deficiencies in technical quality of exams. / Conducts complete exam, some areas show technical inadequacies. / Technically sound complete exam. Generally recognizes and appropriately follows leads from history or other components of the exam. / Thorough, detailed exam. Careful attention to areas relating to problems identified in history. Exam findings are consistently accurate.
4. Oral case presentations Not applicable/not observed
Presentation very disorganized and incomplete with no psychosocial information. / Presentations incomplete. "Holes" in characterization, chronology and diagnostic information. Historical diagnostic information incomplete. / Acceptable delineation of primary problems with reasonable characterization. Attempts to chronicle key events in pt's illness and psychosocial history. Presentation contains acceptable diagnostic information. Presentation complete but not always appropriate focused. / Early clear delineation of primary problems with excellent characterization and accurate chronology of key events in pt's illness. Presentation contains appropriate differential dx information. Consistently appropriate focused presentation. Integrates psychosocial information.
5. Record-keeping (write-ups and progress notes) Not applicable/not observed
Recorded findings are inadequate and/or often written late. Inability to incorporate data into problem analysis or development of adequate problems list. / Lapses in recording findings with omissions and inaccuracies. Occasionally lacks ability to organize information or analyze new data, as it relates to differential dx and/or pt management. / Record keeping is appropriate; analyzes problems in complete manner. Therapeutic program is complete. Good documentation of diagnostic and therapeutic plans and interventions. / Outstanding, conscientious and accurate in recording findings; problem list complete; excellent formulation of pt's difficulties including differential dx and treatment and prevention.
6. Problem-solving and clinical applications Not applicable/not observed
Usually lacks ability to integrate History, PE, and lab/study data in the identification prioritization and solving of clinical problems. Does not consider prevention. / Often limited in ability to integrate History, PE, psychosocial and lab/study data in the identification, prioritization and solving of clinical problems. / Usually reflects integration of History, PE, psychosocial and lab/study data in the identification, prioritization and solving of clinical problems. Considers some prevention issues. / Consistently reflected integration of History, PE, psychosocial and lab/study data in the identification, prioritization and solving of clinical problems and addresses appropriate preventive medical issues.
C. PROFESSIONAL AND PERSONAL ATTRIBUTES
7. Professional attributes and responsibilities Not applicable/not observed
Cannot be relied upon. Attendance and punctuality are erratic. Student's whereabouts often unknown. Needs prodding frequently. Am concerned over student's commitment. / Needs reminders in the fulfillment of clinic responsibilities including pt care. / Can regularly be relied upon in fulfilling responsibilities as a member of the clinic team and in the delivery of pt care. / Exceptionally conscientious. Outstanding in attendance, dependability and pt care responsibilities. Makes an extra effort to be integral team member and assumes high levels of pt care responsibilities.
8. Self-improvement and adaptability Not applicable/not observed
Unaware of own weakness or despite awareness of weaknesses refuses to consider or make changes. / Resistant or defensive in accepting criticism. / Accepts criticism when offered. Makes an effort to change. Does some supplemental as well as required reading. / Outstanding in soliciting and receiving criticism. Able to effect change. Self-motivated to expand knowledge. Intellectually curious and open; makes an extra effort to learn pt's problems; extensive supplemental reading.
9. Relationships with patients and families Not applicable/not observed
Often insensitive to pt's feelings, needs and wishes. Lacking capacity for empathy. Does not demonstrate understanding of importance of family in patient's illness. / Sometimes has difficulty establishing rapport with pts or communicating with them. Not always comfortable interacting with others. / Relates well to most pts and family members. Seems to enjoy pts and family members and the role as a developing physician. / Outstanding in putting pts and/or family members at ease and appropriately communicating medical information to them. Relates well with difficult pts. Shows empathy, compassion and respect.
10. Interpersonal relationships with other members of health care te Not applicable/not observed
Insensitive to needs, feelings and wishes of health care team members. Poorly integrated into the team. / Sometimes has difficulty relating well to health care team members. / Relates well to most of the health care team members. Functions well within the ward team structure. / Outstanding in respecting the feelings, needs and wishes, of all health care team members. Highly integrated into the ward team structure.

Summary Comments: A REQUIRED part of the evaluation (in general terms reflect on any of the above, or any other characteristic, skills, behaviors or attitudes) that will go in the Dean's Letter.

Constructive Comments: Optional --NOT for use in the Dean's Letter. For student and advisor to use in improving skills.

Recommended grade:Honors Near Honors High Pass Pass Fail

Please note students who receive Honors should be exceptional or outstanding in the majority of categories. Only 15-20% of all students in this course should receive Honors.

Please print out and return evaluation to: Carol Whitener, UCSD, Department of Family and Preventive Medicine, Mail Code 0696, 9500 Gilman Drive, La Jolla, CA 92093-0696, Fax #858 822-3990.