General Information

INTRODUCTION

You are about to begin a sequence of two required Externships.  Those problems and medical conditions in Internal Medicine that every physician should be able to manage, regardless of chosen specialty, will be emphasized.  We will provide you with clinical and diadactic experiences that should stimulate learning. 

The goal in Medicine 7-500 is to have you identify clinical problems in your patients through the integration of information derived from the history and physical examination. You will use knowledge of pathophysiology and clinical epidemiology in order to develop a reasoned differential diagnosis.  Finally, you will plan a logical and practical diagnostic evaluation, using the principles of evidence-based medicine.

Your resident, attending physician, and tutors have also been provided with this booklet.  The information included is to assist in setting expectations for these courses, for yourself, and for the faculty.  Each course is to be viewed as a successive part of the educational continuum; those medical problems and skills that you do not learn in Medicine 7-500 should be mastered in Medicine 7-501.  Course Objectives for the Externships in Medicine are intended to help you set your own goals

The ability to learn independently is an essential trait for every physician to have and very important for your success in these externships.  You will have opportunities to evaluate and take care of patients, discuss cases with your resident and attending physician, present cases to both teachers and student colleagues at Case Presentations, and participate in Tutorials addressing common clinical problems.  Each of these experiences should stimulate you to ask questions and to seek answers using the medical literature where appropriate.  In particular, the student conferences will present opportunities for you to actively participate in clinical problem-solving.  The degree to which all students are prepared to do so will largely determine how successful the Externships in Medicine will be as educational experiences for you and your colleagues.

Assignment to Hospital Sites and Orientation: Student assignments to periods for clerkships are made by the curriculum affairs office.  Each clerkship is offered at multiple sites, and the maximum number of students assigned to each site is determined according to clinical resources (patients, faculty, number of resident teams at site).  We have made judgment that exceeding these limits would impair student education.  No student will be assigned to the same hospital site for both medicine clerkships.

Sites:  Multiple sites are used for these clerkships, including:  Abbott-Northwestern (7-5000 only), HennepinCounty, FairviewUniversity, RegionsHospitaland Minneapolis VA Hospital (7-501 only).  Some Duluth students will take 7-500 in Duluthso they can move directly from Duluth to their RPAP assignment.

INTRODUCTION FOR FACULTY AND RESIDENTS

The Department of Medicine has a major responsibility for guidance of student development throughout the four years of medical school, and the Medicine Externships (Medicine 7-500 and 7-501) are integral to the overall educational process designed to foster clinical competence.  There are significant differences in emphasis between the two clerkships.  It is essential that all tutors, attending physicians and residents understand the Course Objectives and schedule as they relate to their particular student(s).  This will enable both student and teacher to share the same goals and to establish reasonable expectations and will allow the process of evaluation to be fair and objective.

Setting expectations should be an initial activity.  We encourage you to sit down with all learners and teachers  (students and residents and attending) to set expectations on Day 1 of the rotation.  This should include:

1. Go over the student and resident schedule to understand what will take them off the ward (include scheduled core conferences, resident clinic schedule, understanding of days off)
2. Understand learners goals
3. Clarify your expectations of students regarding patient care
4. Set a schedule of times you will round
5. Tell students what you value in student performance

The clerkship committee expectations of students are detailed in the evaluation forms found on E*Value. Upon completion of the first medical externship (Medicine 7-500), the student should be able to conduct a complete general physical examination and appropriate special examinations.  In addition to identification of relevant symptoms and physical findings, the student should know the pathophysiologic basis and clinical correlates of these findings for problem identification and problem solving, and based upon a reasoned differential diagnosis be able to plan an adequate diagnostic evaluation using principles of evidence-based medicine.  Students in the second medical externship (Medicine 7-501) will continue to practice and develop these skills and begin to participate responsibly in the management and treatment of patients.

An effective way to encourage independent learning is to use rounds as a stimulus.  Faculty and residents are encouraged to provide students with positive direction through both questions and assignments.  Identify “knowledge gaps” which are directly important to care of current specific patients and assign students to do a (5 minute) minitalk on the topic during attending rounds in two days.  Students really value the opportunity to develop some focused expertise, contribute to teaching and to patient care.  Every encounter, clinical or conference, should provoke discussion, questions, and the mutual search for answers.  Preparation by students prior to ward rounds, seminars and tutorials is necessary because they will actively participate with student colleagues and faculty in solving problems. Faculty can frequently help by suggesting additional source materials or direct literature searching to aid in the student’s search for information.

Ongoing thoughtful and supportive feedback from faculty and residents is critical.  Feedback should be timely and focus on specific strengths or areas needing improvement providing the student with an opportunity to identify and correct any problems noted during the course.  Any potentially serious deficiencies or problems perceived in student performance should be brought to the attention of the hospital coordinator as early in the rotation as possible.  Formal midrotation feedback will be student-initiated at midrotation  (see Feedback below).

Supervision:  The hospital coordinator at each teaching site bears the primary responsibility for the development and maintenance of a program to fulfill the learning objectives of the Externships in Medicine.  The coordinator is responsible for organizing the tutorials and seminars and encouraging faculty members to take the expected approach toward student involvement in seminars and tutorials.  Since there are differences in student responsibilities for Medicine 7-500 and 7-501, coordinators will also reinforce at the beginning of each period, with the attending physician and resident, the objectives to be met by the students assigned to their ward team.

Each student is part of a medical team usually consisting of one or two first-year residents, a senior resident, and an attending physician.  Some teams may pair students (subinterns) with an attending physician without residents.  Students in both Medicine 7-500 and 7-501 attend morning work rounds each day and participate in attending rounds as scheduled.

The attending physician has the primary responsibility for educating students assigned tothe ward team.  The immediate day-to-day supervisor for students is the senior resident. All of the physician-teachers with whom the student has contact are expected to serve as positive role models.

Conferences:  Each clerkship has developed student-specific seminars (listed below).  Most topics are common to all of the sites, but the presentation has been developed at the site.  These are mandatory conferences and students are expected to attend and participate.  Each site has a student specific schedule.  Departmental conferences are routinely held at each of the hospitals.  These conferences include medical grand rounds, morning report, clinicopathological conferences, resident teaching conferences, and subspecialty conferences.  Students are welcome at departmental conferences, although, if student-specific conferences are scheduled at the same time you are expected to attend those instead.

Textbooks:  Students are expected to do some reading in a general medicine textbook as relates to conference topics and to their patients.  

General Concise Textbooks

1. 1. Medical Knowledge Self-Assessment Program, MKSAP for Students 3, American College of Physicians, (Suggested)
   2. Internal Medicine Essentials for ClerkshipStudents, American College of Physicians (Suggested)
   3. For more detailed reviews go to: http://www.im.org/CDIM/ResourcesFor/EducationalTools/CDIMBookReviews.htm

Work-ups and Write-ups: Medicine 7-500 students are expected to work-up a minimum of twelve patients during the rotation.  Medicine 7-501 students are expected to work-up a minimum of fifteen patients.  Students who, through no fault of their own, do not reach the required minimum, will not be considered deficient.  More cases may be assigned. Students should attempt to complete their history and physical examinations within 60 minutes.  Cases will be presented to the attending physician during attending rounds.  It is at this time, or previously in review with the senior resident, that factual historical items should be substantiated and physical findings corroborated. 

Valued Student Performance Behaviors:  The course committee has had many discussions about what makes an outstanding student and resident.  Medical knowledge, skills in gathering and organizing data, and excellent judgment are all essential components.  Perhaps most important is attitude.  Students who are self-starters, who create opportunities for their own learning, who take obvious pleasure in the learning opportunities on the ward are students who will stand out for us.  Look at the evaluation forms.  If you are always bringing in new information for the team, you will be highly regarded.  Accept constructive criticism as a help to your improvement (don’t be defensive).  If you don’t know, don’t make something up.   If you complain about reading and do it only grudgingly, if you complain about learning value of patients admitted to you, these are red flags Before you complain, be sure you have something to complain about.  (See Troubleshooting below)

Feedback:  Since ongoing feedback is fundamental to a successful educational relationship, students should feel free to ask about their progress.  Feedback from faculty and residents to students is extremely important in providing the opportunity to improve clinical performance.  During the Externships in Medicine, students will be expected to initiate meetings at mid-rotation, first with their supervising resident (if assigned) and then with their attending physician, to discuss both strengths and areas needing improvement.  The content of this feedback is outlined in the Evaluation forms for this course (Appendix D – note different forms for resident and attending). 

A similar process should occur at the end of the rotation so that the student, resident and faculty can discuss the student’s progress relative to the mid-rotation assessment and the Course Objectives.  These student-initiated sessions should make the feedback process more efficient, effective, and palatable for the faculty and residents; and equally important, promote student self-assessment through analysis of specific examples of their own performance.