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Medicine I Core Clerkship

Clerkship Objectives and Expectations


Twelve Week Program

Students at the Beth Israel Deaconess Medical Center will be introduced to the whole range of experiences that internists encounter on both general medical wards and general medical and subspecialty ambulatory settings.

Eight Weeks in One of Four General Medicine Firms

The clerkship is designed so that students will acquire skills necessary to evaluate and manage common problems in internal medicine. To gain these skills, students will spend eight weeks on one of four general medicine firms, admitting one patient on alternating long-call and short-call days. A special effort will be made to give students a varied experience, and there will be great flexibility in choosing admissions for student evaluation.

In addition whenever possible, students will see patients first, with adequate time allocated to take complete histories, to perform complete physical exams, to discuss patients' problems with intern and resident, to write complete admission notes, and to seek out information about patients' problems in relevant textbooks and peer-reviewed literature.

Four Weeks in the Ambulatory Setting

In addition to eight weeks on the wards, each student will spend four weeks in the ambulatory setting. During this component of the course, students will be paired with a faculty preceptor. Each student will have a continuity preceptor with whom the student will work two half-days per week throughout the four-week block.

In addition, students will rotate through several medical subspecialties (three half-day sessions each week), dermatology (two half-day sessions each week), an urgent care setting (one half-day each week), and ophthalmology (one four-hour session per block). As much as possible in all of these sessions, the student will have the opportunity to perform problem-oriented history and physical exams, to review each encounter with a faculty preceptor, to develop a differential diagnosis, and to devise an evaluation and treatment plan.

This comprehensive, balanced experience should prepare students to handle medically diverse issues inside and outside the hospital setting, while enabling students to deal with subsequent clerkship rotations and ultimately internship.

Information and Skills Acquired During Clerkship

Students will be expected to:

  • Take a thorough history
  • Perform a detailed and accurate physical exam
  • Formulate a thoughtful differential diagnosis
  • Design a plan of evaluation of their patients' clinical problems
  • Develop skills in presenting their patients' problems lucidly to medical colleagues
  • Perform urinalyses and examine urine sediments, peripheral blood smears, and gram stains of sputum samples and other body fluids on patients they admit and follow and patients cared for by the medical teams

In acquiring these basic skills, students will:

  • Learn to do routine procedures on the medical wards, such as phlebotomy and placement of intravenous lines.
  • As occasions arise, students will also have opportunity to draw arterial blood gases and to perform lumbar punctures, thoracenteses and abdominal paracenteses.

It is hoped that these experiences will foster growth in each student's clinical judgement while consolidating development of sophisticated approaches to both simple and complex medical problems. By the end of the 12-week clerkship, students will be expected to possess a broad working knowledge and a thorough understanding of the pathophysiologies and therapies of basic, common problems in internal medicine.

Emphasis on Total Care of the Patient

Great emphasis is placed on the total care of the patient. With this in mind, it is anticipated that students will acquire sensitivity to the whole spectrum of a patient's encounter with illness, including psychological as well as medical aspects of the patient's care.

Major Duties and Responsibilities


Inpatient Rotation

On inpatient rotation, students are considered an integral part of the Firm's medical team, working closely with one intern and a team resident under the supervision of the ward's Firm Chief and/or Associate Firm Chief and two Co-Attending Physicians.

  • Students take admissions with their assigned team on an every-other-day alternating schedule of "long" and "short" calls.
  • Students remain in hospital overnight on "long call" days (every fourth night) and are excused from taking "short call" admissions on weekends and holidays.
  • It is the student's duty and responsibility to work-up, evaluate, present, and follow their admitted patients daily.
  • The total patient load for each student at any given time should ideally number no less than three and no more than five patients.
  • Work-ups will be closely supervised by the team intern and resident. Students will present their patients in each instance to the Co-Attending Physicians, and at times to the ward's Firm Chief or Associate Firm Chief.
  • Teaching is conducted at the bedside and in the conference room.
  • Students will have full responsibility for writing all orders and progress notes on their patients, scheduling tests, arranging consults, attending family meetings, and following their patients in as close a manner as possible with the intern.
  • When students are not available to carry out these responsibilities, students should be sure to review with their team results of patient evaluations and pending items for further follow-up.

Ambulatory Rotation

On ambulatory rotation, students will work closely with a faculty member in all sessions.

  • Students will see patients independently with their continuity preceptor, present each case, and write notes summarizing each patient encounter.
  • In addition, students will have the opportunity to schedule follow up visits.
  • Primary goals include learning to obtain a focused history, physical exam, assessment and diagnostic plan in the time-limited ambulatory setting, as well as evaluating patients with undifferentiated complaints and formulating a differential diagnosis.
  • In all sessions, students will have the opportunity to review patients seen and to discuss assessments and management plans with their faculty preceptors.

Behavioral and Ethical Expectations

(e.g., confidentiality, discretion, patient interactions, attendance, dress code, etc.)

Students are expected to be present at all scheduled sessions with preceptors and and to be present at all scheduled student rounds and lectures. Promptness is appreciated. It is expected that the students will exercise careful judgment in their interactions with patients as well as their medical colleagues.

Expected Preparation for Clerkship


Suggested Texts for Review


Prior to Clerkship

Dubin's Introductory Textbook of Electrocardiography or Goldberger's Introductory Electrocardiography.

During the Rotation

Harrison's Principles and Practice of Internal Medicine; Cecil and Loeb's Textbook of Internal Medicine; Branch's Office Practice of Medicine; Goroll's Primary Care Medicine.

Books to Purchase

See above (optional).

Instruments to Purchase

  • Stethoscope
  • Ophthalmoscope
  • Otoscope
  • Reflex hammer

Teaching Modes Used During Rotation


Didactic Sessions for Medical Students Only

In the first month of the 3-month clerkship, students will attend 8 EKG lectures (2 lectures weekly) by Dr. Ary Goldberger.

Inpatient Rotation

On inpatient rotation, students will meet weekly as a group with Dr. Reed Drews and weekly as a group with Teaching Residents.

Ambulatory Rotation

On ambulatory rotation, students will meet twice weekly as a group in sessions conducted separately by Drs. Sara Fazio and Carol Waksmonski. Additionally on ambulatory rotation, students will attend dermatology and ophthalmology lectures, organized by Drs. Harley Haynes and Frank Berson.

Weekly Lecture Series

The whole student group (both inpatient and ambulatory) will attend a weekly series of 12 lectures on topics basic to internal medicine. These lectures will be given by faculty members and chief medical residents who are highly regarded for their teaching skills.

Didactic Conferences for Residents and Medical Students


Medical House staff and Students on Rotation

Two weekly lecture series, Primary Care Conference and Thorndike Rounds, are designed specifically for medical house staff and students on rotation. Both lecture series cover a broad spectrum of topics in internal medicine and other disciplines germane to the practicing internist. Invited speakers are BIDMC and other Harvard Medical School faculty who are considered experts in their fields.

Junior and Senior Residents

Junior and senior residents attend "residents' report" daily, and interns attend "interns' report" twice weekly. Drs. Robert Moellering and Steve Weinberger, Chair and Vice-Chair of the Department of Medicine, respectively, preside over these reports, where cases are reviewed and discussed by the Chief Medical Residents with a focus on evidence-based medicine. Students are invited to attend interns' report.

Department Conferences for Faculty, Residents and Medical Students

Two weekly conferences, Medical Management Conference (conducted by the Chief Medical Residents) and Firm Conference (conducted by ward Firm Chiefs or Associate Firm Chiefs) bring together hospital faculty, residents and medical students to discuss patient cases addressing challenging diagnostic, evaluative and medical management issues.

Medical Grand Rounds

Medical Grand Rounds hosts invited speakers, not only from BIDMC and other HMS-affiliated hospitals, but also from medical centers throughout the country. Topics cover a broad range of subjects, bridging basic science and clinical investigation with medical practice.

Clinical Crossroads

On occasion, Medical Grand Rounds hosts "Clinical Crossroads," a series funded by the Robert Wood Johnson Foundation and directed by Drs. Tom Delbanco and Rich Parker. Invited guest speakers, highly regarded nationally and world-wide for their particular expertise, discuss topics posing controversial management decisions. Video-taped interviews with the patient and their physician are a special highlight of these rounds, illustrating difficulties often encountered in clinical decision-making.

Teaching Rounds

Two faculty members assigned to co-attend for one month on one of four inpatient general medicine Firms conduct teaching rounds with the Firm's medical students and house staff three times weekly and accompany the Firm's teams on work rounds at the bedside once weekly.

Once weekly, the Firm Chief or Associate Firm Chief conducts teaching rounds with the Firm's medical students and house staff. Firm Chiefs and Associate Firm Chiefs for the 4 general medical Firms are: Firm A, Drs. George Eliopoulos and Booker Bush; Firm B, Drs. Rob Shmerling and Martin Abrahamson; Firm C, Drs. Sanjiv Chopra and Gerry Smetana; and Firm D, Drs. Mark Aronson and Preetha Basaviah.

Once weekly, the Firm Chief or Associate Firm Chief conducts bedside "walk rounds" with the firm's junior and senior residents and medical students.

Additional Conferences for Inpatient Medical Teams

Department of Radiology staff members conduct radiology conferences daily, in the mornings just before Firm teaching conferences. These conferences provide important opportunities for the Firms' Co-Attendings, house staff and medical students to review radiographic exams obtained on their hospitalized patients and to perform clinicoradiographic correlations.

Faculty members of the Department of Pathology conduct autopsy conference once weekly in the hospital's autopsy suite. Directed by Dr. Melissa Upton, these conferences provide important opportunities for hospital faculty, house staff and medical students to perform clinicopathologic correlations. While gross autopsy findings are a chief focus of these weekly meetings, one conference each month reviews and discusses microscopic pathology findings of cases examined in previous gross autopsy conferences.

Ambulatory Preceptor Sessions

Faculty members in general medicine, subspecialty medicine, dermatology, ophthalmology and Emergency Medicine precept students rotating through these various ambulatory settings.

Student-Directed Reading

To enhance understanding of subjects discussed at conferences and in teaching rounds, students are expected to read relevant textbooks and current peer-reviewed literature. In addition to reading materials suggested and/or distributed by residents and faculty, students will have unlimited access to literature search programs, such as Paperchase and various internet web sites, all available on computer terminals throughout the hospital. The Institute for Education and Research provides additional educational resources, such as the Virtual Patient Program, developed by Dr. James B. McGee.

Students Presentations

On inpatient rotation, students will present their cases on work rounds and at radiology conferences daily, at co-attending rounds two to three times weekly, and on occasion at Firm conference. On ambulatory rotation, students will present many cases daily, for students will be evaluating a number of patients during each outpatient session.

Expectations of Residents and Attendings as Teachers


Role of the Intern

Interns play an important teaching role in the following areas: They assist with teaching students how to write orders, do certain procedures, arrange testings and consults, and find and interpret lab and study results. They discuss on a daily basis management issues relating to jointly managed patients. They read, correct, and countersign students' daily progress notes. And they contribute to case-related teaching that occurs on work rounds, Attending rounds, etc.

Role of the Resident

Residents review the expectations of the student on the ward service and set expectations that are unique to the service and to the resident's teaching style. Residents are expected to engage in case-based teaching surrounding each of the patients admitted by the student. This entails ensuring adequate data collection by the student; reviewing the student's understanding of each problem and the plan for work-up and management; reviewing the student's admission write-ups; "coaching" the student's case presentations, customized for various educational and conference settings; and assisting the student with development of a knowledge base.

Residents are also expected to provide immediate and on-going feedback, both good and bad. Residents should meet at least with the student, in the middle and at the end of the resident's time with the student, to review expectations, progress, problem areas and plans for improvement.

Role of the Attending

Attendings are expected to meet separately with students twice weekly to hear case presentations, review write-ups, and provide feedback. It is the Attending's responsibility to provide mid-course, and end-of-rotation student feedback and evaluation.

Clerkship Organization


Number of students on rotation?

16 maximum; 4 minimum (beginning July 1999).

Do students work with partners?

No. However, while on inpatient rotation, two students (but never more than two students) may be assigned to each Firm team (see below), with each student working with one of the two team's interns.

Do students work with a teaching resident?

Yes, in weekly group sessions while on inpatient medicine.

Do students have a tutor?

Yes, a faculty preceptor during the ambulatory month.

Is there a centralized education office at the hospital?

Yes.

What is the division of time among services?

( e.g., wards, emergency room, CCU, etc.)

Eight (8) weeks are spent on the medical wards (Firms), and four (4) weeks are spent in the ambulatory setting. All students spend the first 4 weeks of the clerkship on inpatient medicine. Thereafter, the student group divides in half, each half rotating on inpatient medicine or ambulatory medicine in either the 5th- through 8th- or the 9th- through 12th-week block of the course.

Required "on-call" schedule and duration of "on-call" at the hospital:

Students are on-call, staying in-hospital every fourth night from 8 a.m. the day of call until 5 or 6 p.m. the following day.

"Team" composition:

2 Interns and 1 Assistant Resident (either junior or senior) comprise the "long-call" team. While students assigned to the team may be on Core Medicine I rotation or Core Medicine II rotation, no more than 2 students will be assigned to a single team. Since each general medicine Firm has two teams, no more than 4 medical students will be assigned to a single Firm. Each Firm has 2 Co-Attending Physicians, 1 Firm Chief, and 1 Associate Firm Chief.

Evaluation


By?

Interns, Residents, Co-Attending Physicians, Firm Chief, Associate Firm Chief, Ambulatory Continuity and Sub-Specialty Preceptors, and Clerkship Directors.

Criteria?

(All of equal importance): Ability to do history and physical exam; ability to do case presentations; ability to do differential diagnosis and evaluation plan; fund of knowledge; and attitude, level of interest, and personal interactions.

Type of exams?

A mid-course exercise is administered to students across all Core Medicine I sites, generally on Monday of the seventh week of the course. Using blue-books, students are asked to outline their approach to evaluation and management of one or two cases illustrating basic medical problems that arise in common practice.

Formal feedback mechanism?

Feedback is available to students at any time upon request from residents, attending physicians, and clerkship co-directors. In addition, formal sessions are held mid-way through each month and at the end of each month, with students meeting with attending physicians who have had direct responsibility for the student's learning. At mid- and end-course, the clerkship co-directors meet in sessions with each student to give composite feedback received from all individuals with whom the student has worked (Interns, Residents, Attendings, Firm Chief and Associate Firm Chief).

General Comments

At the Beth Israel Deaconess Medical Center, we are very interested in students learning and seeing a broad spectrum of internal medicine in a relaxed and enjoyable atmosphere conducive to education. From the house staff to the Chief of Medicine, the student clerkship has the highest priority, and every effort will be made to insure that each individual is given the opportunity to thrive to the greatest extent possible.