The third year Internal Medicine Inpatient Clerkship is a 6-week rotation with the over-arching goal of acquainting students to the evaluation and treatment of adults hospitalized with acute medical illness. Emphasis is placed on developing the skills to diagnose common clinical conditions and to recognize clinical presentations of common diseases. This is facilitated by enhancing the skills used in taking a patient history, performing a comprehensive physical exam and formulating problem lists with appropriate differential diagnosis.

Teaching and learning in the context of patient care is vastly different from learning in the classroom. On the inpatient service the questions to be answered are posed by the patients and the healthcare team. Answering such questions is an excellent way to learn about the patient while also solidifying the students’ knowledge base by learning the scientific and clinical material. Students will participate in the evaluation of a diversity of patients as part of a team of residents and students under the supervision of an internal medicine faculty member.

The clerkship will also provide students with opportunities to enhance their knowledge of core training problems and to develop basic clinical skills (such as EKG and CXR interpretation, physical diagnosis skills) through scheduled structured teaching sessions. These sessions are facilitated by a Teaching Resident, a third-year Internal Medicine resident specifically selected to teach M3 and M4 students on Internal Medicine. Students are encouraged to use these structured teaching sessions to guide their learning and to use the variety of patients encountered to enrich their knowledge base through hands-on experience and targeted reading.

The learning experiences on inpatient internal medicine follow the continuum of self-directed learning established in the first 2 years of medical school. This type of learning is crucial in a field which like internal medicine is not static. Developing patient based learning patterns will allow students to adapt to the changing body of knowledge and will help students become effective, efficient clinicians.

As Sir William Osler said, “The important thing is to make the lesson of each case tell on your education.” It is important to learn something from every patient by identifying one question that is not understood. By going to textbooks, journals and peers to find the answer, students learn and are able to apply this knowledge in the clinical setting. The retained images of patients will not only serve as the ‘outline, lecture notes and laboratory’ wrapped into one, but their many wonderful stories will also serve as a rich resource for student reflection.

Professionalism

The student will demonstrate commitment to scholarly excellence with continued self-assessment and growth of knowledge and skills, and dedication to patient care treating others with mutual respect and dignity.

    Objectives:

1. Demonstrates a commitment to personal excellence (timeliness, attitude, initiative) and professional development (initiative, self-reflection, and seeking constructive feedback).
2. Demonstrate sensitivity and competence in working with others of diverse backgrounds, anticipating the influence of culture on illness and health decisions.
3. Demonstrates honesty and integrity in accurately conveying information and in documentation.

Patient Care

The student will be able to evaluate and manage adults hospitalized with acute illness and convey this information facilely on patient care rounds.

    Objectives:

1. Obtains, records, and communicates an accurate history and physical exam.
2. Utilizes supplemental laboratory and diagnostic studies to support the most likely diagnoses.
3. Interprets the clinical information by prioritizing a problem list
4. Begins to demonstrate reasoned therapeutic decision-making for basic core problems.
5. Presents patients in the context of daily care rounds (abbreviated presentations) and new patient presentations (comprehensive).
6. Documents clear and accurate admission and progress notes on each patient.

Medical Knowledge

The student will demonstrate understanding of the clinical presentation, basic physiology, evaluation, and management of diseases frequently encountered in the inpatient internal medicine setting.

    Objectives:

1. Initiates an assessment and management plan on the following diseases/clinical presentations:< >Acute myocardial infarction/coronary syndromeHeart failureAcute kidney injuryChronic kidney diseaseAltered mental status (delirium)DyspneaFeverFluids and electrolytes< >hyper/hypokalemiahyper/hyponatremiabasics of fluid managementGastrointestinal bleedingLiver diseaseNosocomial infectionPneumoniaVenous thromboembolism/pulmonary embolismDemonstrates a basic approach to interpretation of EKGs, CXRs, and acid-base problems.
2. Demonstrates an understanding of the indications, techniques, and complications of basic procedures.

Practice-based Learning and Improvement

The student will develop life-long learning skills used for improving patient care and fostering continued professional growth and development.

    Objectives:

1. Based on a self-assessment, creates a set of personal goals for the clerkship and reflects on personal progress, modifying as necessary.
2. Demonstrates an initiative in seeking and applying new knowledge in the clinical setting.
3. Applies an evidence-based medicine approach to addressing questions that arise in the clinical setting.
4. Develops a reading/study plan that will work in the clinical setting.
5. Responds to constructive feedback and suggestions for improvement over the course of the clerkship.

Interpersonal and Communication Skills

The student will continue to develop effective interpersonal and communication skills needed to establish and maintain professional relationships with patients, families, colleagues and other members of the health care team.

    Objectives:

1. Speaks with patients and their families using terminology that they understand.
2. Exhibits communication that is compassionate and sensitive when interacting with people from a variety of cultures and backgrounds.
3. Communicates in a facilitative, effective and efficient manner with members of the health care team.
4. Educates colleagues as appropriate.
5. Provides accurate and complete verbal presentations for assigned patients.
6. Develops well organized and accurate patient notes.

Systems-based Practice

The student will develop an understanding of how health care is delivered in a hospital setting as well as resources available and the limitations encountered when caring for patients.

    Objectives:

1. Works as an effective member of the health care team, demonstrating reliability, initiative, organization, and helpfulness.
2. Gains an understanding of interdisciplinary coordination and planning required when transitioning patients from the inpatient to outpatient setting.
3.  Acts as the patient’s advocate.

Responsibility for Learning: The process of learning involves integrating new knowledge with prior experiences and information to create a broader understanding. It requires reflection, planning and self-assessment.

Medical knowledge, skills in gathering and organizing data and excellent judgment are components of behavior that describe an outstanding student. Yet, perhaps the most important behavior is attitude. Students who create opportunities for their own learning, take pleasure in learning and who are willing to teach others are highly regarded by other team members.

It is a satisfying experience for students to carry forward the knowledge and skills developed in the first two years of medical school, as well as in their clerkships preceding the Inpatient Internal Medicine Clerkship, and see the integration of multiple disciplines in providing patient care. Medical knowledge from the basic science courses and Foundations of Clinical Practice, as well as concepts from Biomedical Ethics and Health Law, have particular relevance when dealing with patients hospitalized with acute illness. We hope that students will develop a solid foundation of skills and knowledge that will be applicable across the continuum of their training not only in internal medicine, but across all specialties.

Professionalism: The Department of Internal Medicine emphasizes the importance of this competency in the clerkship because it is the framework of all we do and who we are. It is a lifelong commitment to personal excellence and continued professional development. It is a standard of conduct towards our patients, as well as healthcare colleagues, and demands we aspire with each encounter to achieve the following expectations:

• Show respect for time, both for clinical experiences and learning opportunities
• Show respect towards others
• Dress professionally
• Demonstrate appropriate behavior under stress
• Deliver the best possible care to each individual patient, regardless of race, age or ethnic differences
• Conduct oneself in an ethical manner
• Take responsibility for learning
• Maintain patient confidentiality and discuss patient information only with those involved in the patient's care

Clinical Experience: Students are considered to be important members of the inpatient team assigned to the internal medical service for the care of patients. As part of the teams, students should expect to work with residents, attending staff, specialty consulting physicians and other healthcare personnel. The clerkship emphasizes the importance and rewards of experiential learning. Through direct patient contact and increasing responsibility for patient care, by observing the skills of residents and staff and by ongoing self-directed learning, students will acquire the clinical knowledge and skills necessary to care for patients. Both written and oral communication skills are emphasized. Students will learn to elicit an accurate history, perform a focused physical exam, formulate a reasoned differential diagnosis for each patient problem and begin to develop appropriate treatment plans for these problems. In addition, students will learn to synthesize this information into a concise presentation and to communicate medical information through comprehensive, well-developed medical documentation. Students make invaluable contributions to patient care and are encouraged the students to learn and experience as much as they can during the rotation.

Conferences: There is great breadth to internal medicine and while it will not be possible to teach students all of the body of knowledge during the six-week clerkship, there are a number of scheduled conferences that are available to students to supplement the clinical experiences.

Case-based Learning (CBL): During the clerkship interactive teaching sessions dedicated to internal medicine core topics are offered. The Teaching Resident facilitates this learning experience.

Internal Medicine Grand Rounds: Each Thursday afternoon at 1:00 pm in Med Alumni Auditorium (E331 GH) the Department of Internal Medicine presents Grand rounds. Students are expected to attend two (2) Grand Rounds during the six-week rotation.

Resident Core Conference: Monday through Friday residents come together for educational sessions. Students are invited to join their teams at these sessions.

Community Time: The Department of Internal Medicine feels it is important that students remain connected to their Learning Community and that they continue to promote and support the vertical integration of student life and medical education, two key goals of the Learning Communities. Every Tuesday from 12:30 PM to 1:30 PM is designated on the schedules as "Community Time." During this time students are encouraged to return to their community space in the MERF to check mail, meet friends or make new friends over lunch, and engage in conversation with M-1's and M-2's who are anxious to learn what students are experiencing in the clinical years. Please take advantage of this opportunity to share knowledge of the third year with the first and second year students who are anxious to know what might be in store for them as they progress through the curriculum and move from the basic science years to the clinical years.

By focusing on problems that are common to the ambulatory setting, the Outpatient Internal Medicine Clerkship is designed to provide students with the experiences and teaching necessary to develop specific competencies for the practice of outpatient internal medicine.  During the four-week clerkship students will share in the challenges and rewards of caring for patients with a variety of illnesses as well as spend time thinking critically about these diseases with the Internal Medicine housestaff and faculty.

The clerkship focuses on what students have traditionally found valuable on the rotation:  Teaching Clinics with selected Internal Medicine faculty offer one-on-one teaching and mentoring; exposure to a variety of subspecialty clinics as well as to a broad range of diseases; and, an opportunity to see patients with chronic diseases who are doing well.  In addition, students will have the opportunity to learn from selected Internal Medicine “Teaching Residents.”

This educational experience in clinical medicine is designed to build upon the curriculum students covered in the pre-clinical phase.  During the clerkship students will gain skills and knowledge specific to the practice of ambulatory medicine as well as to continue to build the clinical skills necessary to be a competent physician.  The clerkship goals overlap with other core clerkships and are aimed at developing competent and caring physicians.  Self-directed learning will also be very important to the student’s success on this clerkship and in the remainder of the final years of medical school.  The retained images of patients along with the knowledge gained from reading and learning about patient problems will quickly come to replace outlines, lecture notes and the laboratory.

Professionalism

The student will demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.

Objectives:

1. Demonstrates a commitment to following the bioethical principles of the medical profession:  autonomy, beneficence, nonmaleficence, truth-telling and confidentiality.
2. Demonstrates a commitment to personal excellence (timeliness, attitude, initiative) and professional development (initiative, self-reflection, and seeking constructive feedback).
3. Demonstrate sensitivity and competence in working with others of diverse backgrounds, anticipating the influence of culture on illness and health decisions.
4. Demonstrates honesty and integrity in accurately conveying information and in documentation.
5. Demonstrates teamwork and respect toward all members of the healthcare team.

Patient Care

The student will provide patient care that is compassionate, appropriate and effective when evaluating and managing adult patients in the outpatient setting.

Objectives:

1. Obtains, records, and communicates an accurate history and physical exam appropriately using a comprehensive or focused approach.
2. Utilizes supplemental laboratory and diagnostic studies to support the most likely diagnoses.
3. Interprets and synthesizes the clinical information in developing a diagnostic and therapeutic management plan.
4. Demonstrates a commitment to involve the patient in their own care.
5. Communicates effectively and demonstrates caring and respectful behaviors when interacting with patients and their families.
6. Works with healthcare professionals to provide patient-focused care.

Medical Knowledge

The student will demonstrate understanding of the clinical presentation, basic physiology, evaluation, and management of diseases frequently encountered in the outpatient internal medicine setting.

Objectives:

1. Defines, describes and discusses the following diseases/clinical presentations:< >Health Patients< >Health promotionPatients with a symptom, sign or lab abnormality< >Abdominal pain Back pain CoughDyspneaGastrointestinal bleedingNutritionObesityRheumatologic problems/knee painPatients with a known disease< >Chronic renal failureCOPDDiabetes mellitusDyslipidemiaHeart failureHIV infectionHypertensionSmoking cessationSubstance abuseCommon cancers (lung, colon, breast)Integrates and applies the basic and clinical sciences to the understanding of clinical problems in the ambulatory setting.

Practice-based Learning and Improvement

The student will develop life-long learning skills used for improving patient care and fostering continued professional growth and development.

 Objectives:

1. Based on a self-assessment, creates a set of personal goals for the clerkship and reflects on personal progress, modifying as necessary.
2. Demonstrates initiative in seeking and applying new knowledge in the clinical setting.
3. Applies an evidence-based medicine approach to addressing questions that arise in the clinical setting.
4. Develops a reading/study plan that will work in the clinical setting.

Interpersonal and Communication Skills

The student will demonstrate effective interpersonal and communication skills needed to establish and maintain professional relationships with patients, families, colleagues and other members of the health care team.

Objectives:

1. Speaks with patients and their families using terminology that they understand.
2. Exhibits communication that is compassionate and sensitive when interacting with people from a variety of cultures and backgrounds.
3. Communicates in a facilitative, effective and efficient manner with members of the health care team.
4. Communicates accurate, complete and organized oral presentations of patients’ problems.

Systems-based Practice

The student will develop an understanding of how health care is delivered in the ambulatory setting as well as resources available and the limitations encountered when caring for patients.

Objectives:

1. Works as an effective member of the health care team, demonstrating reliability, initiative, organization, and helpfulness.
2. Gains an understanding of interdisciplinary coordination and planning required for the implementation of treatment plans.
3. Advocates for quality patient care and assists patients in dealing with the system’s complexities.
4. Practices cost-effective health care and resource allocation that does not compromise quality of care.

Responsibility for Learning: The process of learning involves integrating new knowledge with prior experiences and information to create a broader understanding.  It requires reflection, planning and self-assessment.

For the Outpatient Internal Medicine Clerkship, it is assumed that students will carry forward the knowledge and skills developed in the first two years of medical education as well as from the clerkship experiences.  Medical knowledge from the basic science courses and Foundations of Clinical Practice as well as concepts from clinical education will have particular relevance when dealing with patient problems and the care of these patients.

Students will learn in many ways during this elective; through reading, observing others, working with patients, practicing skills, self-assessing and receiving feedback. Students will be expected to assume responsibility for learning during this elective as well as to spend time reading to help build and increase the fund of knowledge about the problems of internal medicine patients.

Professionalism: The Department of Internal Medicine emphasizes the importance of this competency in the clerkship because it is the framework of all we do and who we are.  It is a lifelong commitment to personal excellence and continued professional development.  It is a standard of conduct towards our patients, as well as healthcare colleagues, and demands we aspire with each encounter to achieve the following expectations:

• Show respect for time, both for clinical experiences and learning opportunities
• Show respect towards others
• Dress professionally
• Demonstrate appropriate behavior under stress
• Deliver the best possible care to each individual patient, regardless of race, age or ethnic differences
• Conduct oneself in an ethical manner
• Take responsibility for learning
• Maintain patient confidentiality and discuss patient information only with those involved in the patient's care

Clinical Experience: During the clerkship experience emphasis is placed on the acquisition of clinical knowledge and skills such as performing a history and focused physical examination, diagnostic reasoning, synthesis of this information into a concise presentation and planning a complete workup.  The students’ role in the outpatient clinics is to actively and independently examine patients and to then discuss them and have them “staffed” by a faculty attending.  Faculty will assess the students’ ability to be an effective and accurate oral reporter of information gathered and physical exam findings discovered during the course of the patient encounter.

Students will attend clinic with teaching faculty 7-8 times during the clerkship.  This is an intensive one-on-one precepting experience designed to help the student understand the Internal Medicine approach to patients who present in the outpatient setting.   Students will focus on core ambulatory internal medicine patient problems as well as the clinical skills listed above.

Students will also have the opportunity to see patients in a number of the Internal Medicine subspecialty clinics during the clerkship.  Under the guidance and supervision of a faculty physician, students will work up patients with problems specific to the specialty areas of internal medicine and will develop management plans tailored to these particula patient problems.

Conferences:

Case-based Learning (CBL):  Three times during the clerkship a one-hour session will be dedicated to CBL cases which are part of the ongoing APM series.  The Outpatient Internal Medicine clerkship will cover congestive heart failure, back pain and abdominal pain in these sessions.  The Teaching Resident facilitates this interactive learning experience.

Divisional Teaching Conferences:  A number of divisions in Internal Medicine are responsible for presenting a weekly teaching conference to review Outpatient internal Medicine core topics by integrating medical knowledge with direct patient care.  These teaching sessions are held throughout the week and will be given at times that do not conflict with clinic assignments.  Students are expected to attend and actively participate in these conferences.

Internal Medicine Grand Rounds:  Each and every Thursday at 1:00 PM in Med Alumni Auditorium (E331 GH) the Department of Internal Medicine presents Grand Rounds.  Students finished with their morning clinics are expected to join fellow classmates on the Inpatient Internal Medicine Clerkship at this conference at least once during the four-week rotation.

Community Time: The Department of Internal Medicine feels it is important that students remain connected to their Learning Community and that they continue to promote and support the vertical integration of student life and medical education, two key goals of the Learning Communities.  Every Tuesday from 12:30 PM to 1:30 PM is designated on the schedules as "Community Time".  During this time students are encouraged to return to their community space in the MERF to check mail, meet friends or make new friends over lunch, and engage in conversation with M-1's and M-2's who are anxious to learn what students are experiencing in the clinical years. Please take advantage of this opportunity to share knowledge of the third year with the first and second year students who are anxious to know what might be in store for them as they progress through the curriculum and move from the basic science years to the clinical years.

Ambulatory Practice Module: Education days are held throughout the 12-week Ambulatory Practice Module.  Students are expected to attend the education days which fall between the 4-week clerkships of Outpatient Internal Medicine, Family Medicine and the Community-based Primary Care Clerkship.