INTERNAL MEDICINE SYLLABUS

EXTERNSHIP

Elizabeth Kirkland, M.D., M.S.C.R., Associate Clerkship Director

Mary Ann Snell, Student Education Coordinator

Medical University of South Carolina

Charleston, South Carolina

2018 - 2019

Overview

The General Medicine Externship rotation is structured to provide fourth-year students a broad-based experience in managing acutely ill general medicine patients. This rotation is designed to develop the clinical skills necessary to diagnose and treat undifferentiated medical patients with a wide range of illnesses. The rotation provides each extern with “the intern” experience, directly supervised by expert faculty individually and with a 2nd or 3rd year resident.The student is an integral part of the hospital team, and rotates call schedules and admits patients with the interns.There are several different General Medicine Teams on which students rotate:4 at the main hospital,1 at the ART, and 3at the VAH.

Goals

  1. Enhance the extern’s history taking and physical diagnosis skills to the level of an intern.
  2. Develop differential diagnoses and formulate treatment plansfor acutely ill patients at the level of an intern.
  3. Manage the inpatient illnesses commonly encountered in general internal medicine.
  4. Care for at least 4 patients at a time. Students may be asked to carry more if the team census permits.
  5. Identify the indications for appropriate subspecialty consultation.
  6. Provide appropriate pain control for acute and chronic pain.
  7. Discuss clinical goals and challenges of end of life care.

Objectives

  1. Patient Care
  2. Demonstrate proper techniques for interviewing a patient to obtain a medical history and performing a physical examination in a concise and efficient manner.
  3. Demonstrate analysis, synthesis, and integration of pertinent patient data at the level of an intern.
  4. Formulate appropriate, justified and prioritized differential diagnoses.
  5. Demonstrate an ability to build a positive, healing relationship with a patient.
  6. Document clinical care and thought processes in a standardized format for all patients seen and presented.
  7. Professionalism
  8. Demonstrate professional demeanor and ethical behavior.
  9. Medical Knowledge
  10. Apply knowledge of the pathophysiology, epidemiology, and natural history of diseases to the diagnosis and management of common patient conditions in Internal Medicine.
  11. Begin to learn about and apply knowledge of the pathophysiology, epidemiology, and natural history of diseases to the diagnosis and management of rarer patient conditions in Internal Medicine.
  12. Identify the indications for appropriate subspecialty consultation.
  13. Describe appropriate interventions for pain management for acute and chronic pain.
  14. Discuss communication and clinical strategies for end of life care.
  15. Interpersonal Skills and Communication
  16. Present patient data gathered from patient interviews, physical examinations, laboratory sources, and progress notes on patients, in standardized, concise and efficient format.
  17. Document patient data gathered from patient interviews, physical examinations, and laboratory sources, in H&Ps and progress notes in standardized format. Be able to document patient data quickly and efficiently while managing several patients at the same time.
  18. Demonstrate effective and professional interpersonal and communication skills in interactions with patients and families, including an awareness of psychosocial factors related to patients’ problems.
  1. Practice Based Learning and Improvement
  2. Use evidence-based medicine to guide patient care decisions.
  3. Identify errors in patient care and knowledge deficits, and change future practices based on past mistakes.
  4. Use information technology successfully to access and manage patient information.
  1. Systems Based Practice
  2. Demonstrate appreciation and collaboration with other members of the health care team including nursing, social workers, care managers, pharmacists, and other allied health professionals.
  3. Identify issues related to the cost-effectiveness of diagnostic evaluations and patient care.

STUDENT RESPONSIBILITIES

  • All Internal Medicine courses adhere to the “Medical Student Supervision and Teaching Policy” approved by the MUSC COM UCC on June 15, 2012.
  • Students are allowed to see and perform non-invasive exams on patients that have been assigned to them by their attendings or residents unsupervised. For invasive exams (breast, genital, rectal), a resident or attending physician must be present.
  • Students are allowed to participate in ANY procedure that is common to internal medicine with approval and supervision by the certified healthcare provider (this includes but is not limited to: the nurse, respiratory therapist, resident or attending physician) performing that procedure. This includes but is not limited to IV or central line placement, ABGs, lumbar punctures, arthrocentesis, thoracentesis, or paracentesis.
  • Externs are expected to interpret all EKGs and chest x-rays performed on their patients with the assistance of their upper level resident and attending physician.
  • New Patients:
  • History and Physical: Perform a complete history and physical examination on new patients admitted to the hospital. In addition, students are expected to collect all relevant imaging and laboratory data that is available at the time of admission.
  • Documentation: Students are expected to document their admission history and physicals. Initial H&Psmust reflect the student’s ownfindings and opinions. Student cannotplagiarize the written assessment and/or plans of other providers. Initial H&Ps should include the chief complaint, history of the present illness, review of systems,past medical history, surgical history, family history, social history, medications, physical examination, assessment, problem list, differential diagnosis for each problem, and a clinical plan regarding further evaluation of in order to establish the appropriate diagnosis. Include treatment plans and issues related to short and long term prognosis whenever possible.In general, assessment and plans should reflect that the student has both read and learned about the possible diseases under consideration for a particular patient.
  • Presentation of the new patient to the attending: This presentation will occur after the patient has been admitted. The presentation should consist of a logical, orderly, concise presentation of the patient’s history and physical examination findings. Students should be prepared to go to the bedside to demonstrate the relevant findings and discuss further history with the patient. Students should have any relevant imaging, graphic, or laboratory data related to the patient available at the time of the presentation. Students are expected to have an assessment, problem list, differential diagnosis, and plan ready to present. Although residents will assist students with developing assessments and plans, students should not rely on residents to come up with the plan of care for their patients.
  • Current Patients:Each extern should be carrying 4-5 patients at a time.
  • STUDENTS ARE EXPECTED TO ATTEND INTERN–INTERN CHECKOUT EVERY MORNING.

INTERN/INTERN HANDOFF: Students are expected to attend morning checkout daily while on day shifts – including weekends. Please ask the Chief residents and your team for details of where checkout occurs.

  1. Pre-Rounds:
  2. Every morning students will see their assigned patients, interview them to see how they are doing, and speak to ancillary staff to find out if there were any significant events over night.
  3. Students will collect all other data that has been obtained in the past 24 hours, including but not limited to vitals, physical exam, new labs, new radiology and results from other procedures.
  4. Students mustwrite a daily progress note in the medical record of all patients they are following. Students are encouraged to discuss assessments and plans with residents prior to attending rounds.
  5. Attending Rounds: Each morning the Attending will round with the entire team. Students should present the significant data relating to their patients obtained during pre-rounds.
  6. After Rounds:Students are expected to participate in the team’s clinical work, including writing orders, prescriptions, ordering radiology studies, updating patients, completing medical documentation, etc.
  7. Afternoon rounds: Students are strongly encouraged to independently see their patients in the afternoon to follow up on the issues identified in the morning. If a patient was vomiting, hasit stopped? If a patient was in pain, and the analgesic regimen was adjusted, is the patient still in pain? Students should report any updates or new findings to their residents, so that the residents can help address any issues.
  8. Students are expected to read about each of their patients on a daily basis.
  • Evening/Night shifts:
  • Night shifts are an opportunity to evaluate new patients and to participate actively in the evaluation and management of inpatients who are acutely ill.Thus, students should work closely with the intern on call, accompanying him or her to the bedside, working up and evaluating emergency admissions.
  • Students are expected to be in the hospital during night shifts. Lack of availability is considered patient abandonment, a violation of professional ethics, and is considered grounds for failure of the course. Students’ responsibility is to be in the hospital, even if told to go home by residents.
  • An evening shift is until 8PM on General Medicine. Externs will do 3 evening shifts during the rotation.
  • Students are strongly encouraged to coordinate their evening shifts with their team’s schedule, such that the students are staying until 8PM when the team’s interns are staying until 8PM.
  • Night shifts
  • Students on a teaching team are assigned 5 night shifts in a row. Shifts are from 7:45PM until 8:15AM. Students are to attend resident-to-resident patient handoffs.In addition, students are welcome to stay for morning report after nightshifts, but this is not mandatory.
  • Call rooms: We are not required to provide call rooms because night shifts constitute shift work
  • Ashley River Tower: There may not be enough call rooms. However, if students anticipate wanting a call room, the room needs to be reserved with the concierge at ART 1st floor desk. Rooms can be reserved the day of or one day before a night shift, but not earlier than that.Rooms are available on a first come, first serve basis. The available call room number is ART 2414. The phone number for the concierge is 843-876-4252.If you have reserved the room, but it is locked, please contact Security at 843-792-2261. Please DO NOT knock on the door if it is locked.
  • Main Hospital: There is a call room located at 124 CSB. The code to the outside door is 124. The code to the inside female door is 952.
  • Days off: Students get 3 weekend days off during this rotation. The rotation will be complete at the end of the work day on the last Friday.
  • Please take a few minutes to read the Student Agreement on page 9, and turn in a signed copy to Mary Ann Snell.

ACTIVITIES

TIME

/ Monday / Tuesday / Wednesday / Thursday / Friday
Before Morning Report or Morning Rounds / Pre-Rounds / Pre-Rounds / Pre-Rounds / Pre-Rounds / Pre-Rounds
8:00 – 9:00AM / Grand Rounds
Location to be determined
8:00 – 9:00AM / MorningReport
(4th fl Med Conf Room VAH) / MorningReport
(4th fl Med Conf Room VAH) / MorningReport
(4th fl Med Conf Room VAH)
8:30 – 9:30AM / MorningReport
(MUH – 300 CSB) / Morning Report
(ART – 1119 ART) / MorningReport
(MUH – 300 CSB)
9:30 – 11:30AM / AttendingRounds
(MUH)
AttendingRounds
(VAH) / AttendingRounds
(MUH)
AttendingRounds
(VAH) / AttendingRounds
(MUH)
AttendingRounds
(VAH) / Attending Rounds (MUH)
Attending Rounds
(VAH) / Attending Rounds
(MUH)
Attending Rounds
(VAH)
12:00 – 13:00PM / NoonConf.
300 CSB / Noon Conf.
300 CSB / Noon Conf.
300 CSB / Noon Conf.
300 CSB / Noon Conf.
300 CSB

*Please note: lectures with the Chiefs may be at any point in the afternoon. You will be notified of the schedule as soon as it is made.

MORNING REPORT: Conference with presentations of new and interesting patients, led by theChief Residents at each hospital. Attendance required by students on inpatient service.Students MUST swipe in or sign the book at the VA.

GRAND ROUNDS: Weekly presentation in either the Bioengineering or IOP Auditorium. All inpatient students are required to attend. Students DO NOT swipe in.

NOON CONFERENCE: This conference is for the residents (therefore, as an extern you should attend) in order to cover the basic topics of Internal Medicine. Please note, sometimes this conference will be about resident business or recruitmentand students are excused in those cases. Noon Conference is in 300 CSB unless otherwise notified. Students DO NOT swipe in.

GRADING POLICY

Feedback: Feedback to externs will occur principally through a mid-point evaluation form, completed by the attending at the two week mid-point of each month rotation. Students will get one additional card to be filled out by either a resident or an attending. Students should also meet formally with the attending at the end of the rotation to discuss performance.

Evaluation: The Medicine Externship is graded on an Honors-Pass-Fail basis.

  1. Honors:
  2. A student in 4th year will be eligible for clinical honors if they achieve an Overall Performance score of 2.8 or higher (4 out of 5 “exceeds expectations” on average) and have:
  • No ratings of “does not meet expectations” on EPA Performance or Overall Performance
  • No ratings of “major concerns” for Professionalism or Communication
  • End of rotation presentation: achieve an Honors on the presentation [a score of 20 out of 25 on the presentation evaluation form.]
  1. We follow the COM Clinical Course Assessment and Grading Policy: “Policy: 4th Year Electives and Externship Failure (Approved on June 15, 2018): Each Elective, Externship, and required course, sets criteria for failure, pass, and honors for the course prior to the start of each academic year. These criteria will be made available to students at the beginning of each course in written form. All clinical faculty and rotations will assess the clinical performance of students using the standardized COM Clinical Performance Evaluation (CPE).

A student will fail a course if any one of the following conditions is met:

  • A Clinical Performance Evaluation noting the following deficiencies regarding a student:

1)Does Not Meet Expectations for EPA Performance

  • A majority of evaluations have ≥ 2 ratings of “does not meet expectations” or ≥ 3 ratings of “building competence”
  • ≥2 ratings of “does not meet expectations” or ≥ 4 ratings of “building competence” in a course that issues only one evaluation.

2)Major Concerns noted in Professionalism or Communication

  • A majority of evaluations note “major concerns”
  • At least 1 evaluation notes a major professionalism concern that is deemed egregious

3)Does Not Meet Expectations for Overall Performance

  • A majority of evaluations have ≥ 2 ratings of “does not meet expectations”

4)At the discretion of the course director, a student may fail the clinical performance evaluation when fewer than the majority of evaluations note significant concerns in EPA Performance, Overall Performance and/or Professionalism or Communication and are supported with narrative feedback from evaluator(s).

  • A failing grade on any secondary component of the grade [a score of 20 out of 25 on the presentation evaluation form.].
  • Additionally, a student is eligible for failure at the discretion of the course director for unprofessional behavior. A professionalism form must be completed and submitted to the COM Dean’s office.

What if a student fails some component of the grade?

If a student fails the clinical component of the grade, the student fails the course and will therefore be placed on academic probation and must repeat the course. If the student fails an Advanced Medicine Elective course, the student must repeat an Advanced Medicine Elective course. If the student fails an externship or elective course, the student must repeat an externship or elective course, respectively, as specified by the Associate Dean for Curriculum, Clinical Sciences.

If a student fails a secondary component of the grade (i.e., Presentation) the student will receive a grade of “Incomplete” (IN) and will have the opportunity to remediate that portion of the grade. The student will not receive honors for the course as a whole regardless of their performance on the remediated portion of the grade. If the secondary component is failed a second time, the student fails the course..

If a student fails a secondary component of the course that requires remediation, the second attempt must occur prior to graduation or within 6 months, whichever occurs sooner. If remediation is not achieved in this time frame, the student will fail the course and will therefore be placed on academic probation and must repeat the course.

Grade Appeal

Students may ask the Clerkship Director to have the Internal Medicine Education Committee review the grade, but this must be done within 30 days of the final grade posting (See Dean’s Office Grade Grievance Policy). The student must complete the IM Grade Grievance Form and turn in to Mary Ann Snell. If the grade is upheld, the student may appeal their grade to the Clinical Sciences Planning and Evaluation Committee. If the matter is not resolved to the satisfaction of the student and the student continues to feel that a wrong has occurred, the student may petition in writing Dr. Donna Kern and Dr. Angela Dempsey for a final appeal.

END OF ROTATION PRESENTATION

  1. Overview: Students are expected to develop a formal presentation regarding a clinical question or topic for the end of the rotation. Students will present their presentations to the other externs on service, the Course Director, and their clinical teams (e.g., attending, residents, interns, and third-year students, as applicable.) The presentation will be evaluated using a standard assessment form to generate a grade for the presentation.
  2. Topics for the presentation: The presentation should focus on a specific clinical question or topic, derived from the student’s clinical experiences during the rotation and specifically from a patient or clinical experience the student actively participated in. General reviews of clinical topics are discouraged. For example, reviewing causes of acute renal failure would be a broad and unfocused topic, while discussing the evidence for bicarbonate administration to decrease the risk of contrast-induced nephropathy would be an appropriate focused clinical question for the presentation.
  3. Content of the presentation: Presentations should be developed using PowerPoint or a related presentation platform. The presentation should be no longer than 12 PowerPoint slides in length, and should clearly demonstrate the student’s research into the clinical topic. Specifics regarding presentation content include:
  4. Title slide – Students must start with a title slide that clearly states the clinical topic or clinical question they are going to discuss.
  5. Context – One or two slides describing why the student chose this clinical topic or question, ideally describing a clinical case or scenario.
  6. Evidence – The majority of the presentation will consist of several slides reviewing 1-3 peer-reviewed articles regarding the clinical topic or question. These slides should specifically identify the studies, delineate the results, and discuss how those results pertain to the question or topic. You should also address the quality of the evidence, taking into account the study design, population, etc. The sources used for this presentation must be from the peer-reviewed literature. UpToDate, Wikipedia, or other general sources are not acceptable.
  7. Synthesis – One or two slides ‘putting it all together’ will synthesize the literature and identify key take-home points.
  8. Answer – The final slide should clearly state an ‘answer’ to the student’s clinical question, succinctly summarizing the ‘evidence’ and ‘synthesis’ slides and bringing the presentation back to the initial clinical question or topic. Basically, how does your research impact how you will treat a similar clinical case in the future?
  9. Duration: The presentation should not exceed 10 minutes. Students will be cutoff if their presentations go longer than ten minutes.
  10. Evaluation: The presentations will be evaluated in five domains. Each domain is graded on a 5 point scale (1 = poor, 5 = excellent). The entire audience (excepting other externs) will evaluate each presentation. The 5 domains for evaluation are:
  11. Clinical question or topic: Does the student clearly identify a reasonable, focused, and clinically valuable question to address? (1 = very broad, unfocused, irrelevant question or topic; 5 = very focused, clearly stated, and clinically relevant question or topic.)
  12. Importance of the question or topic: Does the student clearly justify why he or she felt the clinical question or context is important? (1 = Totally unclear as to why this question or topic is important; 5 = very clear description of why this question or topic is important to clinical care.)
  13. Quality of evidence: Does the student present evidence of sufficient quality to influence clinical practice? (1 = Poor quality of evidence, featuring UpToDate, Wikipedia, or other non-peer reviewed resources; 5 = Excellent quality of evidence, featuring an appropriate number of peer-reviewed, high quality studies.)
  14. Discussion of evidence: Does the student present the evidence about his or her question in a manner that demonstrates understanding and content knowledge? (1 = student does not understand the design, results, or implications of the students he or she is presenting; 5 = student clearly understands the intricacies of the studies presented, and demonstrates detailed knowledge about methodologies, results, and implications of the studies.)
  15. Quality of presentation: Are the PowerPoint slides clear, well organized, and effective? Is the student’s presentation organized and clear? Is the student’s voice audible, and is the oral delivery of high quality? (1 = Disorganized, busy, sloppy slides with spelling and grammatical errors, and/or inaudible presentation and/or very disorganized oral delivery; 5 = very clear, very well organized, and aesthetically pleasing and engaging slides, and excellent oral delivery with appropriate volume, pacing, and organization.)
  16. Students should email their presentation to the Coordinator and the Course Director
  17. Grading:
  • Honors will be 20-25 points
  • Pass will be 15-19 points
  • Fail will be 14 or less points

EXTERN LOG