Guidelines for Students 2007 - 2008
Learning goals for Medicine 665
Knowledge
- Learn a basic approach to diagnosis and management of a broad range of diseases encountered in general internal medicine.
- Learn to use basic medical therapy: diet, activity modification and drugs.
- Learn to recognize and treat major organ system failures.
Skills
- Gain further experience and confidence in history taking and physical examination.
- Refine and condense write-ups and oral presentations to be as precise and efficient as possible in communication about patients.
- Learn to use laboratory tests, radiologic examinations and special procedures, (i.e., blood drawing, intravenous lines, arterial blood gases) to assist in delineating patients' problems.
- Learn to construct differential diagnosis, and be able to support diagnosis based on history, physical exam, and laboratory findings.
- In addition to general clinical skills, we have developed specific benchmarks for three skill sets which will be used for the mini-CEX and the senior OSCE. These skills are:
Experience
- Become involved in the care of individual patients, following these patients from admission to discharge (and beyond where possible).
- Develop an appreciation of the impact of illness in the individual patients and recognize the psychosocial factors which affect medical illness.
- Learn in depth about the specific diseases and symptoms of your patients and develop learning habits which will serve as a model for life-long learning as a physician.
What to do on the clerkship
"The practice of medicine is an art, not a trade; a calling,
not a business; a calling in which your heart will be
exercised equally with your head." - Sir William Osler
- Plan to make the effort required to see, write up, and present at least two or three new patients each week during the clerkship. This means you will often need to see patients between 5 and 9 in the evening and you may have to see patients already examined by an intern (although the housestaff will try to let you be first as much as possible). Stick with these patients, get to know them, and become as familiar as possible with their symptoms, tests, diseases and therapies. You should be responsible for writing orders for these patients and your orders will be cosigned by the residents.
- Ask why specific tests and therapies are being done. The why and when of special tests are as valuable for you to learn as what the tests show. Inquire as to the costs of different tests and medications to gain an appreciation of "cost effectiveness."
- Read selectively. When you read about specific diseases, consult the text book first, then ask your resident or attending for outside references. Harrison's Principles of Internal Medicine, Cecil's Textbook of Medicine or Kelly's Textbook of Medicine are recommended. UpToDate is a good online resource, but may not provide as comprehensive an overview as a "print" textbook. Scientific American Medicine is also a worthwhile text to consult. Most of these resources are available through the HealthLinks Care Provider Toolkit from the UW Health Sciences Library. A "core" list of topics that you should know about will also be covered in a lecture series on Thursday mornings.
The title of the textbook is “Internal Medicine Clerkship Guide", Editors D. Paauw, L. Burkholder, M. Migeon, Mosby, 2007. Please make sure you purchase the 3rd edition. $34.95
The textbook is available for purchase at the University of Washington Health Sciences Bookstore . - To learn the basics of therapy, Medical Therapeutics: A Pocket Companion by Larson and Ramsey is an excellent up-to-date reference.
- For refining physical examination skills, Evidence-Based Physical Diagnosis by Steven McGee is highly recommended. You may also find the following useful: Art and Science of Bedside Diagnosis by Sapira, Bedside Diagnostic Examination by DeGowin and DeGowin or a Guide to Physical Examination and History Taking by Bates.
- Most of you are beginning now to enter a life-time profession of medical practice. The following list of diseases and topics was prepared to assist you in directing your studies of general internal medicine to areas which are widely regarded as important for all medical students and practitioners. You obviously do not have time in the 665 clerkship to learn all about these subjects. For this reason, we have developed the "core" list of topics and the accompanying outlines for the Thursday morning lectures series. You should use this following list as a guide for directing your studies during your third year of medical school. As a practitioner of general medicine, you should be able to carry out all phases of the general medicine management for most patients with these diseases and problems:
Common problems in internal medicine:
ALLERGY
- Allergic rhinitis
- Asthma
- Drug reactions - general mechanisms
ARTHRITIS/RHEUMATOLOGY
- Osteoarthritis (Degenerative joint disease)
- Gout
- Low back pain
- Systemic lupus erythematosus
- Rheumatoid arthritis
CARDIOVASCULAR
- Atherosclerosis - etiology and treatment, coronary artery disease, angina, myocardial infarction, aneurysms, peripheral vascular insufficiency
- Dysrhythmias
- Congestive heart failure - physiology, evaluation, and treatment
- Hypertension - evaluation, treatment
- Valvular heart disease - clinical features, diagnostic methods, interpretation of data
- Evaluation of chest pain
ENDOCRINOLOGY
- Adrenal insufficiency, hyperadrenalcorticalism
- Corticosteroid therapy
- Diabetes
- Hyper/hypothyroidism
- Hypoglycemia
- Parathyroid and calcium metabolism/osteoporosis
GASTROINTESTINAL
- Acute abdomen including pancreatitis
- Cancer - colon, stomach, pancreas
- Cholecystitis
- Cirrhosis
- Diarrhea - diagnosis and management of acute and chronic diarrhea
- Gastritis
- G.I. bleeding - management
- Hepatitis
- Jaundice - differential diagnosis
- Malabsorption
- Nausea and vomiting
- Peptic ulcer disease
- Ulcerative colitis, regional enteritis
HEMATOLOGY/ONCOLOGY
- Anemia
- Bleeding & clotting disorders
- Lymphoma - stages, principles of treatment
- Leukemia, acute and chronic
- Multiple myeloma
- Principles of chemotherapy
- Thrombocytopenia
- Use of blood products - Transfusions Rx
INFECTIOUS DISEASE
- Antibiotic Rx - general
- Cellulitis, Pharyngitis, Otitis
- Endocarditis
- Fever unknown origin
- Meningitis - etiologies, treatment
- HIV infection and AIDS
- Osteomyelitis/septic arthritis
- Pneumonia
- Tuberculosis
- Urinary tract infections - acute pyelonephritis
- Viral infections: hepatitis, infectious mononucleosis, herpes simplex, herpes zoster, influenza, hepatitis
NEPHROLOGY
- Evaluation of hematuria
- Fluid/electrolyte and acid/base management
- Glomerulonephritis
- Nephrotic syndrome
- Obstructive uropathy
- Principles of diagnosis and management of acute and chronic renal failure
NEUROLOGY
- Cerebrovascular disease - stroke syndromes
- Coma
- Headache - DDX - management
- Poisoning - overdose
- Seizures
RESPIRATORY
- Carcinoma of the lung
- Infections of the chest (see Infectious Disease)
- Obstructive lung disease - chronic bronchitis, emphysema
- Pulmonary emboli
- Respiratory Failure - acute and chronic
SKIN
- Cutaneous malignancies
- Manifestations of HIV infection
- Cutaneous signs of internal disorders
- Dermatitis
OTHER
- Alcoholism
- Drug abuse - particularly cocaine
- Emergency care
- Poisoning
- Protein calorie requirements - nutritional therapy
- Obesity
- Geriatric long-term care
- Medical ethics
- Cost awareness
- Weight loss
Guidelines and Expectations
When you report to your assigned hospital, you will be given detailed information regarding the policies and teaching program of the medical service at that hospital. Problems concerning your hospital assignment, general responsibilities and final grades should be brought to the attention of Dr. Paauw.
Your role on the team
Supervision of Clerkship. Each student is assigned to a resident who will make patient assignments, read write-ups, and be available to the student for guidance and advice. You will probably learn more from the resident than any other single individual and should make it a point to look to him/her as your immediate advisor. In addition, you may call upon the interns, residents or fellows in medical specialties, chief resident and faculty members for advice. Don't hesitate to ask questions! Please consult with the chief resident or clerkship coordinator about any problems which cannot be resolved in conference with your resident.
You will be accepted as part of the ward team during this clerkship, and are expected to participate actively in work rounds, attending rounds, and conferences regarding your patients.
Schedule. Team work rounds begin at 8:00 am weekdays, and 8:00-9:00 am (or even earlier) on weekends; check with your team for your weekend schedule. The student’s day ends when all care for patients is complete and last scheduled conference is over.
Assignment of Patients. You should be assigned to a patient at the beginning of the clerkship. Following this you will be responsible for working up at least two or three new patients a week. Patient assignments will be made by your resident and care will be taken to vary the type of disease assigned to you as much as possible. Please keep a record of your patients which includes age, sex and primary medical diagnosis.
Knowledge of Patients. We will expect you to know your own patient in fine detail and you should have this information at hand at any time. In addition, you should become familiar with major problems of other patients on your ward team.
Initial Work-up. Wherever possible you will be encouraged to work-up the patient before the intern and resident. Exception will be made to this when patients are exceedingly sick; in such cases you should work-up the patient jointly with the resident, and your work-up may be curtailed to fit the clinical situation. Do not do pelvic and rectal exams without first checking with the house officer. Pelvics should be performed jointly with house officers. You should ask to write orders for your patients; if so, these must be countersigned by the intern.
Rounds. The student is expected to pre-round in the morning. Pre-rounding consists of checking vital signs, checking lab work, and doing a directed physical exam. Allow 15 minutes of pre-rounding time per patient. The student is expected to “be the expert” on their own patients.
On-Call. You are expected to be available to admit and see patients two nights each week. This is a bare minimum, and we would encourage you to spend as much time as possible on the ward and in the hospital. This will enable you to see patients other than those assigned, observe and perform procedures, and talk to the residents. You should arrange your on-call schedule to fit the admitting schedule of your team as much as possible. Patient write-ups should be in chart by the next morning.
Write-ups. These must be on the chart on the morning following admission on all patients assigned before 8:00 p.m. When patients are assigned during the night, write-ups should be on the chart within 24 hours after admission. All write-ups should be corrected by your resident. Please remind the resident of this, if he or she fails to be prompt in reading your write-ups.
Orders. Orders will be written by the student and co-signed by the intern. If the intern is in clinic, it is okay to ask the resident to co-sign.
Progress Notes. You should write daily progress notes on your patients. These should be clearly signed with your name and identification of your role as a student (e.g. "UW E-03" or "MS3"). If your patient is transferred to another service, you should be familiar with your patient's progress on that service.
Case Presentations. We will attempt to have you present as many cases as possible on rounds. Presentations should be clear and concise. Very rarely should any presentation take more than 4 minutes unless you have been repeatedly interrupted. Rehearse with your resident if you are not sure what is expected. A description of the case presentations expected for Medicine 665 is available on the web site.
Laboratory Work-up. Depending on facilities available, you may be responsible for the admission CBC, urinalysis and stool hemoccult as well as other tests performed on admission (such as Gram stain, gastric analysis, etc.). Follow-up lab work is generally done by the laboratory. You may be responsible for emergency blood work and for drawing blood in the morning on your own patients if such a service is not available.
Procedures. You will be encouraged to draw blood and start IV's. Experience with lumbar punctures, thoracentesis and paracentesis will probably be limited. These must always be done under supervision of a house officer. Whenever possible, you should accompany your patient when major diagnostic or therapeutic procedures are done off the ward.
Professionalism
Absence. Please see the absence policy on the web site. If you need to be absent for reasons of illness, please notify your resident no later than 8:30 a.m. so that your patients may continue to receive essential medical care. If you must miss a scheduled student session, please inform the chief medical resident or hospital coordinator. Excused absence to attend scientific meetings, etc., must be obtained from the clerkship coordinator.
Dress and Deportment. To many patients and members of the hospital staff, bizarre dress or an unkept appearance are as disturbing as unprofessional behavior would be. The ultimate responsibility for dress and deportment on the medical services of our affiliated hospitals rests with the Chief of Service at each of the hospitals. If a resident or attending physician to whom a student is assigned feels the student is showing unprofessional dress, deportment or demeanor, he should report the matter to the Chief of Service for appropriate action.
Conferences, Rounds, and Didactics
Grand Rounds. During the clerkship you are expected to attend Medicine Grand Rounds in Room-T625, 8:00 a.m. Thursday mornings, August - June.
Thursday Morning Conferences. On Thursday mornings from 9:00 to 11:15, regular didactic sessions will be held in the Health Sciences Building (please see lecture schedule for room) for all Medicine 665 students in Seattle. The course textbook will cover the essential topics covered in the lecture sessions. The textbook can be purchases at the University of Washington Bookstore. Lectures during the last six weeks of the clerkship at the WWAMI sites will cover the same topics. The schedule for these sessions will be discussed with you when you arrive at the WWAMI site. Students at Boise will cover the same topics as the students in Seattle, using the same outlines. The schedule for the Boise sessions will differ from the Seattle schedule. This is a required conference series geared entirely for students to cover important diagnostic and therapeutic issues. Visit the following website: http://depts.washington.edu/somclerk/ to view the lectures on the web
Physical Diagnosis Rounds. The chief medical residents in Seattle hospitals and at Boise will schedule a 60 minute meeting with you each week for physical diagnosis rounds. You should have the opportunity to observe many patients with interesting physical findings during these physical diagnosis rounds. Because each of you cannot possibly care for patients with all the common internal medicine diseases, we hope to broaden your exposure to physical diagnostic findings during these rounds. For the students who spend the last six weeks at the WWAMI sites, the attending physicians will teach physical diagnosis.
Course Coordinator Meetings. At each of the sites, the course coordinator will schedule regular meetings with you. During the 12-week clerkship, these meetings will serve several purposes:
The sessions with the course coordinators will focus primarily on discussion of your individual patients. These sessions should involve case presentations and discussions. In the beginning of the course, time may be spent on the mechanics of presentations (see case presentation guidelines), but as the course progresses, more emphasis will be placed on discussing pathophysiology and patient management;
The hospital course coordinator will also meet regularly with you to discuss your progress in Medicine 665. During those meetings, the course coordinator should discuss any problems that you have encountered during the clerkship and should make suggestions for improvement. These meetings will also provide an opportunity for you to ask questions and make suggestions for the clerkship.
Noon Conferences. These are held on a regular basis at each hospital to provide didactic teaching about selected patients and diseases. You should plan to attend these conferences.
Evaluation and grading
Feedback. We strongly encourage you to solicit feedback frequently, and be prepared to offer it in return. We recommend that you meet with members of your team for feedback at least twice during each 4-6 week block: once in the middle to discuss strengths and goals for improvement, and once at the end to review overall performance. Although we ask our residents and attendings to make a point of providing feedback, it is primarily the student's responsibility to request feedback.
Final Examination. Please see the final exam information on the web site. As part of your Medicine 665 clerkship, you are required to take a written examination. This examination is given to evaluate your knowledge of general internal medicine. It will include both multiple choice and patient management questions. You are required to pass this examination to receive a passing grade in Medicine 665. The examination will be given on the last day of the clerkship at each of the sites. In Seattle, the examination will be given in the Health Sciences Building. The same examination will be administered at each of the WWAMI sites and at Boise.
Last minute studying for the examination should not interfere with patient care. The examination has been designed to emphasize aspects of internal medicine which you can best learn from direct patient care. The best way to prepare for the examination is to learn in depth about the specific disease, symptoms and management of your patients. During the clerkship, you should use the outlines for the Thursday morning lecture series to guide your reading about your patients. Some material for the examination may be drawn from these outlines.
MINI-CEX. Completion of a focused clinical examination of a patient with dyspnea is required to pass the Medicine Clerkship. A supervising senior resident, fellow or attending must watch your evaluation of the patient and fill out the Mini-CEX rating form which should be returned to the Student Program Office. You are responsible for arranging the mini-CEX with a supervising physician. Failure to complete the Mini-CEX before the end of the quarter (final exam day) will make you INELIGIBLE for Honors regardless of your other grades.
Grades. Please see the grading policy on the web site. Your grade for Medicine 665 will be based upon your performance in the clinical portion of the clerkship and on the written examination. Final grades for the clerkship (Fail, Pass, High Pass, Honors) will not be assigned until you have completed the written examination. A failure on the final exam will result in an Incomplete grade for the course until the exam is passed. You will be given 4-6 weeks to study and re-take the exam to receive a passing grade. Specific information regarding grades will be covered at orientation during the first week of the clerkship.
Priorities
There are certain priorities to recognize in approaching your Medicine 665 clerkship. The teaching program can be divided into:
- General Teaching Program. This includes case oriented teaching by residents and attending staff, including work rounds, attending rounds and consult rounds. Didactic conferences including medical grand rounds, professor's rounds and noon conferences also fit into this category.
- Student Oriented Sessions. These include the Thursday didactic series, the physical diagnosis rounds and the course coordinator sessions.
Remember that the learning involved with direct patient care is the most important component of your Medicine 665 clerkship. However, all parts of the general teaching program and the student oriented sessions are also important for your Medicine 665 experience. In some instances, other team activities and workl hour limitations may conflict with these essential parts of your program. Unless the team activities are directly related to one of your patients, the components of the general teaching program and student oriented sessions should receive your highest priority. You should, of course, assist the interns and residents in the general work involved in managing the team of patients--especially the patients for whom you have primary responsibility! You should be a functioning member of the team, but remember your educational priorities. If you feel that there is a substantial conflict between your priorities and the expectations of your team, we encourage you to discuss it with the chief resident or site coordinator as early as possible.
We hope that this outline will assist you to perform your duties in Medicine 665. Remember the basic objectives for the clerkship and do not get lost in the details. You cannot learn everything there is to know in internal medicine during this clerkship. You should rely on the course coordinators and the chief medical residents to guide you through the clerkship. They will help you set the priorities for how you spend your time. DO NOT HESITATE TO ASK QUESTIONS.