Internal Medicine Clerkship
Attending Physician Manual
Introduction:
The Department of Internal Medicine at WayneStateUniversity thanks you for your commitment to medical education. You are the backbone of the Internal Medicine Clerkship. In setting the educational and professional tone for your team, you ensure our students receive the highest quality education in Internal Medicine. To facilitate your teaching we have developed an Attending Physicians’ Manual. Many of you are already familiar with the information contained in this manual. For those of you that are new teaching physicians, we hope you find this material helpful. When you have completed reviewing the manual, please sign the attestation your student will provide to you.
Thank you again and enjoy your new role as a teaching physician in Internal Medicine.
Background:
To be able to provide outstanding education it is important to understand the background of students who are assigned to the junior clerkship in Internal Medicine.
In the United States, nearly all medical students have had four years of undergraduate education and a minimum of a bachelor’s degree. A significant minority of WayneStatestudents will also have had additional education, including advanced degrees such as Masters, or experience in the work force.
At WSUSOM first two years of education are devoted to learning the basic medical sciences such as biochemistry, anatomy, physiology and pathophysiology. Students do participate in a course entitled “Clinical Medicine” where they are introduced to the medical interview and begin to learn to obtain a detailed history including a medication history, history of complementary and alternative medicine use (CAM), a detailed social and occupational history and sexual history. In addition, students are exposed to a variety of important topics affecting the delivery of healthcare.
During the second half of the sophomore year students participate in an extensive Physical Diagnosis course. This course is currently being reorganized but will include extensive experience with real hospitalized patients. Students are expected to learn how to do a physical examination. Although exposed to a variety of pathologic findings, students are only responsible for knowing how to do a complete and detailed history and physical examination. Little emphasis is placed on learning pathologic findings.
After completing Year II, students take USMLE Step 1. They begin the third year of medical school with a formal two day Orientation to the Junior Year. The first clinical clerkship generally begins the second week of July.
The Junior Year
The junior year of medical school is the first clinical year for WSU students. Students are assigned to one of two six-month blocks, either a primary care block or a surgical block. During the primary care block, students rotate through two months of Internal Medicine, two months or Pediatrics, and one month of Family Medicine. For the 2004-2005 academic year, students retain the option of electing a second month of Family Medicine or doing an elective in a Department of their choosing. During the primary care block all students participate in a mandatory “Continuity Clerkship” and leave their respective rotation for one half day a week to participate in an ambulatory primary care experience.
During the surgical six month block, students rotate through two months of Surgery, two months of Obstetrics and Gynecology and one month each of Psychiatry and Neurology. Within each block, assignments to specific clerkships are random.
As a consequence of the scheduling, you will notice distinct differences in the way students perform at different times of the year and within each six month block.
Clerkship Orientation:
On the first day of the clerkship, students are required to report to the School of Medicine for a large group orientation. Goals and objectives for the Internal Medicine Clerkship are introduced. Student expectations are discussed. Policies regarding absences are reviewed. Students are provided with information detailed the process by which their performance in the clerkship will be evaluated and how overall grades are awarded. Students are notified of important dates including dates for ACLS*, last day of the clinical rotation the final examination date. Please refer to the Internal Medicine Clerkship Syllabus. Go to Wayne State University Department of Internal Medicine web site @ and click on students.
Following the large group orientation, students report to their respective sites for a site orientation. Contact your Site Director to obtain a copy of the Site specific orientation materials.
*NB: Students will participate in an ACLS course during their rotation but are not certified when they begin the clerkship.
Orientation to your service:
Students generally report to their assigned teams on the second day of the clerkship. They will meet their supervising residents and interns first. You will most likely meet your students during attending rounds. Take a moment to learn a little a little about your students’ background. Find out where they went to collegeand if they “know what they want to go into.” Encourage students to keep an open mind and consider Internal Medicine as a career option. You are a role model for students. Discuss with them how you came to choose internal medicine as your career.
Next,review the goals and objectives for the clerkship with your team members. Although youmay be familiar with the goals and objectives for students on the rotation, your interns and residents may not be nearly as familiar. Remember, these physicians are very involved in the education of junior students providing significant clinical supervision and teaching to students when you are not around. Faculty and students are happier with the evaluation they receive when everyone understands the goals, objectives and expectations. Please review the goals and objectivesin the Internal Medicine Clerkship Syllabus at the end of this manual.
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Please review the expectations section with your student. (See Clerkship Syllabus) The expectations outlined are generalexpectations. The Site Director at your institution reviews specificexpectations such as when your student needs to arrive to the hospital or which conferences are mandatory. However, you too may have specific expectationsfor your students (e.g. how you want presentations done etc). Make sure your student understands your expectations.
In addition to the goals and objectives for the clerkship, students are responsible for being familiar with common problems seen on an in-patient Internal Medicine service. (This can be found in the Clerkship Syllabus too) Review this list and try to discuss an approach to these common problems as they relate to your student patients. You can also assign these specific topics to students to assist in their preparation for the shelf exam. With the start of the 2004-2005academic year, all student in the clerkship will use PDAs to record their educational experiencesin terms of problems, diagnoses and procedures performed. It is hoped that students will have an opportunity to work up or hear about, on rounds or during conferences, each of the “common problems.” Students who do not “experience” a problem will be required to complete a Medcase for that problem. Medcase is a computerized interactive case which provides students with an opportunity to think through various problems and diagnostic cases.
Attending physician expectations:
Attending physicians are expected to teachand guide the studentsto help themachieve the goals and objectives of the clerkship and understand the principles of InternalMedicine. Attending physiciansmust also provide midmonth feedback and formally evaluating student’s performance at the end the clerkship. At the month’s conclusion, teaching physicians must complete theclinical performance evaluation form used by the School of Medicine. This must be turned in to the Site Director on the last day of the rotation. Therefore, it is crucial that you are familiar with the evaluation form with which to evaluate clinical performance on the clerkship. A copy of the form is included at the end of this manual.
Feedback and Evaluation:
Students need to receive feedback.Furthermore, feedback should be well timedand specific so students can incorporate feedback and improve their performance. Students should receive feedback in all areas of evaluation including:
Application of knowledge in the clinical arena
History taking
Performance of a physical examination*
Communication and relationships with patients and families
Professional attributes and responsibilities
Overall knowledge base
Written and oral case presentations
Record keeping (write-ups, progress notes)
Facility with technical skills and procedures
Communication and relationships with health care team
Self improvement and adaptability
Teaching physicians will need to observe students performance in these areas in order to provide meaningful feedback. This can be challenging on a busy clinical service. Here are some suggestions:
Ask questions that probe the students’ knowledge base and the students’ ability to use that knowledge to answer clinical questions. Is the students’ knowledge appropriate for their level of training? Is it “satisfactory” or does it “exceed expectations?”
Provide opportunities for students to demonstrate physical examination skills. Physicians need not observe an entire physical exam, but should have the student demonstrate various components of the physical examination over the course of the month. Many resident use call or work rounds to access student skills in physical examination.
Provide regular opportunities for students to present their new patients and their established patients. What is the quality of the students’ presentations? Are the presentations organized? Does the student present pertinent positive and negative findings or is the student unable to filter important information? How does this student’s presentation compare with other junior students at the beginning, middle, or end of the year?
Provide feedback immediately following presentations using the sandwich technique (First comment on one positive aspect of the presentation, next note an area which can be improved—be specific, end on a positive note. For example, “you certainly had all the information on your HPI, now you need to work on the organization, start from when the patient was in their usual state of health and work forward. You already have the information, now all you have to do is rearrange it. I am confident you can do it.” Lastly make a plan for follow-up. “Why don’t you practice on this HPI and present it to me tomorrow after rounds, that way you will be prepared for the next H&P.”
Provide opportunities for student to discuss their assessment and their plan for patient evaluation and treatment. Can student identify the patient’s primary problem? Can students elaborate a well ranked differential diagnosis appropriate for a junior student? Try to have realistic expectations for your student. Remember this is their first experience on Internal Medicine and in July it is their first clinical experience ever.
Assign topics for your students to present that encourage students to demonstrate the ability to go to the texts and literature to answer clinical questions.
Review documentation (H&P and SOAP notes) noting detail, organization, and thoroughness. Note: Students will be required to turn in one H&P and SOAP note to the site director for formal evaluation and feedback.
Observe interactions with patients, physicians and ancillary medical staff. Does thestudent act professionally?
Does the student take responsibility for his or her patients? Does he or she read about his or her patients’ problems, follow-up on laboratory abnormalities, complete notes in a timely fashion, and discuss significant changes with the supervising interns and resident?
How well does student accept feedback?
Midmonth Feedback:
Midmonth feedback is required. This year the School of Medicine is requiring students to complete a self reflective midmonth formative evaluation form. You will be asked to review the student’s impression of their own performance with them. In addition, you may wish to use the SOM evaluation form when providing midmonth feedback. Students who are told they are doing a good job often believe they will get an “outstanding” evaluation and are very surprised at the end of the month when their evaluation is “satisfactory.” This can be circumvented by providing timely feedback which is reflective of the student’s performance. Please document delivery of midmonth feedback on the end of month clinical evaluation form.
End of the month feedback and evaluation:
At the end of the month, attending physicians should sit down with their students and provide formal summative evaluation and feedback with suggestions for improvement. In evaluating students’ performance please remember that performance tends to improve as the academic year progresses. One should be careful not to under evaluate performance in July and August and not over evaluate performance in May and June. Attending physicians needing guidance in completing the evaluation form should contact the site director at their institution.
Grading:
Both faculty and residents evaluate student performance on the clerkship. Resident physicians should provide meaningful comments on their evaluations form as these are used by the Dean of students for students’ MSPE (Dean’s Letter) used for residency application.
Final Clinical Grade:
The final clinical grade is a composite based on clinical evaluations from attending physicians and resident physicians (but not interns) from both months of the clerkship and is assigned by the Internal Medicine Clerkship Director at Wayne State University. As defined in the curriculum guide, students must receive a majority of “outstanding or “exceeds expectations” in each category to receive “exceeds expectations” in that category. Students receiving seven or more “Exceeds Expectations” on the composite grading form will receive a final clinical grade of “Outstanding.” Students achieving less than seven “exceeds expectations” will receive a final clinical grade of “Satisfactory.” Students with evaluations of “Does Not Meet Expectations” will be closely reviewed by the Clerkship Director to determine if that student fails the clinical portion of the rotation.
Final Grade:
All students must take and pass the national subject examination commonly known as the “shelf exam” to successfully complete the clerkship. The final grade is assigned by the Clerkship Director and is based on both the final clinical grade and the performance on the shelf exam. The Department follows the grading policies of the School of Medicine for Year III Clerkships. (Please consult curriculum guide).
Students scoring 1 standard deviation above the WayneState intra group mean or more on the examination and achieving a composite clinical grade of “Outstanding” will receive a grade of “Honors” for their clerkship. Students achieving an overall outstanding clinical evaluation and a score of at least the WSU group mean will receive a “clinical commendation.” Students achieving 1 SD above the mean on the exam and satisfactory clinical evaluation with receive a commendation for the rotation. Students successfully completing the exam and the rotation will receive a grade of satisfactory. Any student who fails the exam will be given the opportunity to repeat the examination. Students failing the second examination must repeat their rotation to receive credit for the clerkship.
Closing:
The success of the clerkship in Internal Medicine relies on you and on your ability to teach and to evaluate student clerks on your service. The Department of Internal Medicine depends on resident physicians to role model, encourage and inspire students to become future internists.
On behalf of the Department of Internal Medicine at WayneStateUniversity
Thank you.
Sincerely,
Diane Levine M.D.
Associate Professor of Medicine
Internal Medicine Clerkship Director
WayneStateUniversitySchool of Medicine
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