University of Hawai'i
Department of Family Medicine
& Community Health
Medical Student Teaching (MST) Division
Third Year Clerkship
Welcome to your family medicine clerkship! We hope to make this experience both interesting and educational and to give you a good sense of what the specialty of Family Medicine has to offer. The goal of the family medicine clerkship is to introduce students to the care of patients and their families as a first access provider. Students will see patients from all age groups and with a wide spectrum of concerns and problems. These include health care maintenance issues (including screening and prevention), life habit counseling (i.e. smoking cessation, diets), acute illness management (i.e. sinusitis, tendonitis), and chronic illness management (i.e. asthma, diabetes, depression). Indigent health care, sexual and reproductive health, behavioral medicine, community medicine, sports medicine, cross-cultural sensitivity, evidence-based medicine and medical informatics are also important components of the curriculum. To supplement your primary preceptor experience, you may also rotate with preceptors who specialize in or have special interests in sports medicine, geriatrics and home care, as well as prison medicine. You will also staff the H.O.M.E. (Homeless Outreach & Provider Education) Project student-run free clinics or participate in caring for the homeless at other community sites during your clerkship.
Please make sure that you contact your preceptor before the start of the rotation. If you are having difficulty reaching your preceptor, please notify our office as soon as possible. Keep in mind that all of our community preceptors volunteer their time to work with our medical students and that they all have busy practices that they must keep up with in addition to teaching you. Although each clerkship site is different, your patient care experiences will be monitored and we will make sure that you obtain an adequate exposure to family medicine at whatever location you are placed.
Although we try to take into account your site preferences for placement, we are not always able to accommodate all students’ requests. If at any time during the rotation you feel strongly that your particular placement site is not working well for you, please notify the clerkship director as soon as possible.
By the completion of a third-year family medicine clerkship, the medical student is expected to possess, at a level appropriate for a third-year student, the knowledge, attitudes, and skills needed to:
1) Provide personal care for individuals and families as the physician of first contact and continuing care in health as well as in illness.
2) Assess and manage acute and chronic medical problems frequently encountered in the community.
3) Provide anticipatory health care using education, risk reduction, and health enhancement strategies.
4) Provide continuous as well as episodic health care, not limited by a specific disease, patient characteristics, or setting of the patient encounter.
5) Provide and coordinate comprehensive care of complex and severe problems using biomedical, social, personal, economic, and community resources, including consultation and referral.
6) Establish effective physician-patient relationships by using appropriate interpersonal communication skills to provide quality health care.
Please click here for complete Goals and Objectives and also refer to Required Topics for the Family Medicine Clerkship.
1) Preceptor Experience
a. Each 6L student is expected to spend two half days per week with a family medicine preceptor for the duration of their ambulatory 6L experience. In addition, you will be expected to participate in 8 additional half-days of department specified supplemental experiences (i.e. extra H.O.M.E. or PCM clinics).
b. Your preceptor should be observing your history taking and physical exam skills when possible. Your preceptor(s) needs to sign you off on the history and physical exam checklist by the end of your rotation.
c. Although clinic notes that you write on a day to day basis will vary greatly depending on what site you are at, you should try to write a complete formal SOAP note on at least 1-2 patients per week. You should ask your preceptor to review these notes for you. If you do not receive feedback on your formal notes from your preceptor, please inform Dr. Lee or Dr. Omori before the end of the rotation so that you can obtain adequate feedback prior to your end-clerkship OSCE.
d. If your preceptor goes on vacation or is unavailable for a period of time, please let the clerkship coordinator know ASAP. In this case, you can either work with a FM colleague of the preceptor in a site that has been approved for teaching by the clerkship coordinator or you will be assigned temporarily to another preceptor.
e. All students will spend at least two half days during their clerkship at the Physician Center at Mililani to broaden their experience.
f. Some preceptors will require their students to do in-patient rounds and call at their affiliated hospitals.
2) H.O.M.E. Project and Other Supplemental Experiences
a. Oahu based 6L students will staff the H.O.M.E. project student-run free clinic either at the Waianae homeless shelter or at the Kalaeloa Shelter one half-day per week. Clinic hours for Waianae are Tuesday afternoons from 2-6PM. Kalaeloa hours are either Saturday mornings from 830-12 or Saturday afternoons from 1-4. Students based on the neighbor islands may participate in local homeless health care activities in their assigned communities. In addition, students will participate at the Homeless Clinic at the Next Step shelter in Kaka'ako on at least four occasions during the year. Next Step clinic hours are 6-10 PM. You should bring your JABSOM nametag, stethoscope, oto/ophthalmoscope, and blood pressure cuffs to each clinic experience. Please make sure that your equipment is properly labeled. White coats are optional, but please wear your identification/name tags. For the mobile H.O.M.E. Waianae and Kalaeloa clinics carpool sites may be arranges with clinic staff. (Van leaves from Kaka'ako).
b. As part of the H.O.M.E. Project experience, you will be interviewing a homeless individual or family to discover how and why they became homeless. You will also be required to apply for certain resources, including welfare, housing and medQuest that these patients access to experience the same challenges that they must face. You will complete a 1-2 page essay by the end of the clerkship describing your homeless individual/family's story and your experience with accessing resources.
c. Throughout the clerkship, students will also be required to attend supplemental experiences with family physicians that specialize in sports medicine, geriatrics and home care, and prison medicine. Please refer to your individual schedules for the dates/times of these experiences.
d. For each supplemental experience you participate in, please have your preceptors complete the supplemental experience evaluation form (appendix K) and return it to the clerkship coordinator by the end of the clerkship. Although you may not spend a large amount of time with these preceptors, their evaluation of you will be used to supplement your evaluations from your primary preceptor(s).
3) Interactive Web-Cases
During your family medicine clerkship, you will be required to complete a set of patient cases. The cases are based on a hypothetical family and should be completed in the order specified. These cases take the place of PBL sessions in this clerkship and are organized very similarly to PBL cases that you have had in the past. Your answers will not be graded, however, to get full credit you must answer each question thoughtfully and with good effort. If you do not know the answer to a question, you are expected to research that item at the time that you are completing the web-case. Do not answer "I don't know" to any of the questions. Allow yourself 45 minutes to 1 hour to complete each of the web-cases. Each page of the web-cases gets submitted individually once you hit the buttons at the bottom of the page. If you need to stop in the middle of a case, please remember where you left off and when you return to the case, leave the pages that you already completed blank and go forward until you reach the page where you left off. If you wish to receive extra feedback on your progress with the cases, please let Dr. Lee or Dr. Omori know and someone will get back to you as soon as possible. There is a list of resources that goes along with each of the cases and it can be and should be accessed from each page of the case by clicking on the "resources" button in the upper right hand corner of the page. The cases are meant to supplement your learning in family medicine and will assist you in preparing for the end-clerkship examinations. You can access the web-cases from the link on this web-site or at www2.jabsom.hawaii.edu/FamilyMedicine/PreDoc/. You will be given a username and password to gain access to these cases. Grading is pass/fail.
4) Doctor-Patient Seminars
There are four doctor-patient seminars which meet for about two hours each. The purpose is to introduce students to issues that affect the ways that doctors and patients relate to each other and to help develop skills that make that relationship therapeutic and satisfying. There are required readings/videos, which should be done before each session, and two required essays (write-ups). Grading is pass/fail. To pass, you must attend the sessions, participate in group discussions, and turn in the two required write-ups. Please refer to Appendix L for the topics and required readings for each of the seminars. The following are summaries of the required write-ups.
Write-up #1: Narrative of Family Illness (Needs to be turned in at seminar #2)
This paper should describe a time when there was an illness in your family and how this affected you and your family. You will be sharing your story at the second seminar. It should include:
Write-up #2: Finding Common Ground (Needs to be turned in at seminar #3)
This paper should discuss a scenario where you or one of your preceptors found common ground with a patient, or perhaps a time when it would have been useful. This does not have to come from your FM clerkship. You will discuss your paper at the third seminar. It should include:
Participation in the group discussions is evaluated by:
5) Didactic Sessions
There is a series of didactic sessions designed to supplement your clinical learning. These sessions are mandatory and some may require advance preparation. There are other recommended readings that you should also complete during your FM clerkship that will help to supplement your learning. The recommended readings can be found on the CD-ROM that you will receive from the department. You are welcome to copy the CD, however, you will need to return the original to the department at the end of your clerkship.
6) Web-Based Modules
You will be required to complete two web-based modules during the course of your clerkship. One module is on smoking cessation and the other reviews common ENT problems. Your username and password for the modules are the same as that for the web-cases. The link for the web modules is located at the top of this page or go to: www2.jabsom.hawaii.edu/FamilyMedicine/PreDoc/
7) Cultural Competency in Medicine
As part of the FM cultural competency curriculum, we will be having a general orientation session on cultural competency at the start of the clerkship. There are also several readings on the CD-ROM in the health and culture folder. In addition, you will be watching several videos (Wit and Ikiru), after which all students will participate in a discussion regarding culture in medicine. You will also be required to turn in a 1-2 page essay by the end of the clerkship describing how consideration of "culture" affected your decisions, actions, or attitudes in a particular patient encounter or in a variety of encounters. Grading is pass/fail. To pass, you must participate in the discussions and turn in the final essay.
8) MSIII Colloquium
This is a seminar series conducted for all 3rd year students. It will be held once a month on a Friday (entire day) at the Kaka’ako campus (normally from 10:30-3:30 pm). The schedule is available through the Office of Medical Education or Office of Student Affairs.
9) Community Service Activities
You are required to participate in two different types of community service activities during your family medicine clerkship, preferably in the community where you are working during your rotation. These activities can include, but are not limited to, support groups, sporting events, primary/secondary school talks & activities, patient education projects, and health fairs. You will be asked to submit a community service log on-line to document each activity that you participated in. Please refer to the website athttp://www2.jabsom.hawaii.edu/FamilyMedicine/NewPredoc.html for ideas on a variety of community service projects.
10) Patient Logs
Patient log encounter data is required to be kept on a personal digital assistant utilizing the T-Res software. Your FM template will be loaded onto your PDA prior to the start of the rotation. Whenever you synch your PDA, your database will automatically be uploaded to the T-Res website so that our department can track your progress in the clerkship. The data is used to document the range of patient care encounters that you experience. You will receive a summary print out of your patient log half way through your rotation to help guide your patient care experiences. The patient logs will be used to determine whether any supplemental clinic experiences will be needed before the end of the clerkship. Please refer to appendix F for more information on the PDA logs.
The Family Medicine Residency afternoon teaching conferences are held from 1-5 pm every Wednesday in the second floor conference room at the Physician Center at Mililani. Lunch is often provided by a pharmaceutical representative. Check the department website for the current resident conference schedule. (http://www2.jabsom.hawaii.edu/FamilyMedicine/NewResidency.html)
Dershewitz, Ambulatory Pediatric Care, 3rd Edition
Goroll, A.H., etal. (Eds.) Primary Care Medicine, 4th Edition
Graber, M.A. etal. The Family Practice Handbook, 3rd Edition
McWhinney, I.R. A Textbook of Family Medicine, 2nd Edition
Rakel, R.E. (Ed.) Textbook of Family Practice, 5th Edition
Rudy, D.R. NMS Family Medicine
Essentials of Family Medicinee, 3rd Edition
Swanson, R.W. Family Practice Review: A Problem Oriented Approach, 3rd Edition
Weinstock, M., Resident Guide to Ambulatory Care, 4th Edition
E. Family Practice Specialty Board Review,
American Academy of Family Physicians: www.aafp.org
Cochrane Database: www.cochrane.org
Family Practice.com (Practice Test Questions): www.familypractice.com/qanda/qandaframe.htm
Journal of Family Practice POEMS: www.infopoems.com
MD Consult: www.mdconsult.com
National Guideline Clearinghouse: www.guideline.gov
The Provider's Guide to Quality and Culture: http://erc.msh.org (Click on link off of main page)
University of Hawaii Department of Family Practice: http://jabsom.hawaii.edu/familymedicine
University of Iowa Family Practice Handbook http://www.vh.org/Providers/ClinRef/FPHandbook/FPContents.html
U.S. Preventive Services Task Force - Guide to Clinical Preventive Services: http://odphp.osophs.dhhs.gov/pubs/guidecps/
*These are recommended in addition to thereadings on the CD-ROM
1. OSCE (Observed Structured Clinical Exam)
You will be observed (and videotaped) interviewing two standardized patients at the Center for Clinical Skills at the Kaka’ako Medical Education Building (2nd floor Diamond Head wing). You will be given a patient scenario and then you should proceed to take a history as you would in a real situation. In addition to taking a complete history from these patients, you will be expected to perform an appropriate physical exam for each patient. You will also be expected to provide patient education as appropriate. Do not forget to address health care maintenance and prevention issues with these patients. You have a total of 20 minutes to complete your history, physical, and patient education with each patient.
For one of these patients, you will be presenting your findings along with your assessment and plan to a faculty preceptor. You have 10 minutes to gather your thoughts and finalize your assessment and plan after meeting with the patient. You will then present the patient along with your assessment and plan to a faculty preceptor. You have another 10 minutes for this portion of the OSCE.
For the second patient, you will be graded on your SOAP note for the visit. You will have 20 minutes to write your SOAP note. The note should not be documented like an H&P but rather a progress note that encompasses all pertinent positives and negatives and gives the reader an adequate insight into the patient you interacted with. It should be documented in the formal SOAP note format that you learned during your Unit 6 orientation session. You do not need to include a subjective and objective section for each problem, but you do need to include a detailed assessment and plan for each separate problem. DO NOT merely document a problem list. Your assessments should include discussion as well as differential diagnoses for all appropriate problems. You should also be able to commit to the diagnosis that you feel is most likely for problems where the exact diagnosis is not known and be able to justify your decision based on the information you gathered in your history and physical. Your plan should include all aspects of management, including diagnostic, therapeutic, and educational components.
You are allowed to carry any resource materials with you that fit in your coat pockets, so it would be advisable for you to wear your white coats for the OSCE.
In addition to the two standardized patient stations, there will be a third, writing station. For this station, you will be presented with two patient scenarios. Each scenario will be followed by a series of short-answer questions for you to complete. The scenarios and question-types are very similar to those found in the web-cases. The total writing station is worth 30 points (15 points possible per scenario). You will have 30 minutes to complete this portion of the OSCE. Whereas the standardized patients stations are open-book, you may not use your resources to answer the questions in this part of the OSCE.
You will be graded on:
a. The completeness of your history taking and physical exam.
b. Your assessment, plan, and presentation skills: Organization, focus and clarity, ease of following, all-important data included, appropriately prioritized assessment, and plan consistent with patient needs and risk of illness.
c. Your ability to write concise yet complete progress notes. (This will include the legibility and organization of your note).
d. Your physical exam technique.
e. The standardized patients will also be evaluating your skills in the following:
· Personal Manner and Rapport: introduction and greeting, treating patient on the same level (not patronizing), showing interest in patient as a person, acknowledging patient concerns.
· Communication/Counseling: explained medical terms in simple language, listening carefully and not interrupting, asking thoughtful questions, asked for patient opinions and encouraged questions, checked for understanding, being encouraging and empowering.
· Whether they would return to you as a patient.
· Physical examinations skills: washing hands, appropriately draping patient, describing the physical exam and explaining findings, considering patient comfort during the exam, examining underneath clothing.
f. The accuracy and thoroughness of your answers to the writing station questions.
Any questions regarding the grading of the OSCE must be presented to the clerkship director within one week of receiving your OSCE grade.
2) Department Exam
The department exam is a multiple choice exam (approximately 100 questions) based on the didactics, web-cases/modules, recommended reading topics, and common ambulatory care problems. It is a two hour computer based exam that is taken at the Kaka’ako computer lab (1st floor). Instructions for log-in to the exam will be provided prior to the test. Any questions regarding the grading of this exam must be presented to the clerkship director within one week of the examination date.
3) Student Performance Evaluations
Every faculty member, community preceptor, and resident who has a significant role in supervising you during your clerkship completes an evaluation form for you at the end of your clerkship (see Appendix A). These ratings are the major, but not sole determining factor of your overall grade. Forms are returned to the clerkship director who summarizes them. Written comments are separated into two sections: formative and summative. The formative comments are considered diagnostic feedback for your use only. The summative comments should reflect your overall performance. These comments are used in your Medical Student Performance Evaluation. If you have any questions or concerns about comments you receive, we encourage you to talk with your preceptor or the clerkship director.
STUDENT CONDUCT AND RESPONSIBILITY
As a reminder, students at JABSOM are expected to behave ethically and responsibly at all times. Please refer back your General Guide to the M.D. Program for specifics regarding student conduct and responsibility. You can also refer to the University of Hawai’i Student Conduct Code located on the web at www.hawaii.edu/student/conduct/ . We would like to stress that any discussion with other students regarding content or details of either the web-cases and modules, OSCE, or the department exam would constitute a violation of the student honor code. All violations will be handled according to the University’s student conduct policy and could result in expulsion from the medical school. All procedures that you perform should be supervised by medical school faculty, your preceptor/attending physician, or a second or third year resident. Breast, pelvic, rectal, or genital exams need to be performed with a chaperone (clinic staff member, resident, your preceptor/attending physician, or medical school faculty member) present.
Our evaluation of students during the FM clerkship is based on an analysis of knowledge, attitudes, and skills. The grading is assessed as follows:
Minimum requirements to pass:
1. Passing grade from preceptor and average ratings of 2.5 or above (scale of 1-5).
2. Passing grade from didactic sessions and interactive web-cases/modules (Pass/Fail only).
3. Passing grade from doctor-patient and cultural competency sessions (Pass/Fail only).
4. Score of 65% or above on the OSCE.
5. Score of 65% on department exam.
6. The student is also required to turn in:
· Community service log, observed H&P checklist, clerkship objective checklist, FM clerkship CAT form, final patient log, homeless experience essay, and cultural competency essay
· Student evaluation by preceptor (you are responsible for making sure this is turned in)
· Evaluations of FP preceptor/rotation , didactics, and doctor-patient seminars
Minimum requirements for honors (need all to honor):
1. Recommendation for honors by your preceptor.
2. Passing grade from didactic and cultural competency sessions, interactive web-cases/modules, and doctor-patient seminars.
3. Composite score of: (The composite score is your weighted score: Preceptor 40%, OSCE 25%, Department exam 35%)
6L Fall: 88 6L Spring: 90
4. The student must receive an honors level score (85%) for at least one of the end-clerkship examinations.
5. The student is also required to turn in all documents described above.
6. The Family Medicine predoctoral education committee has the right to review all student cases of honors and near-honors scores to determine the student’s final grade.
Remediation in case of failure:
1. If a student fails the preceptor portion, he/she must repeat the clerkship as a 6B student.
2. If a student fails the interactive web-cases/web-modules or cultural competency series, he/she must repeat the clerkship as a 6B student.
3. If a student fails the doctor-patient course, he/she must spend four hours of one-on-one discussion with the course leaders, and re-do the required write-ups. It is then the decision of the course leaders whether to pass the student or not. If they fail the student, then the student must repeat the clerkship as a 6B student.
4. If a student fails the OSCE, he/she will receive an incomplete and have to make-up the exam at any of the block end exam dates, or at the mid-year 6L exam date in April. If the student fails the OSCE on the second try, he/she may have to repeat the clerkship as a 6B student.
5. If a student fails the department exam, he/she will receive an incomplete and have to make-up the exam(s) at a time approved by the clerkship coordinator. If the student fails the exam on the second try, he/she may have to repeat the clerkship as a 6B student or complete a remediation program of at least four weeks as designed by the clerkship director under guidance of the predoctoral education curriculum committee.
6. The predoctoral education committee reviews all students with two failures on department exams and/or OSCEs. Final determination of student remediation will be determined by the curriculum committee with input by the Office of Student Affairs.
7. All remediation must be completed before beginning Unit 7.
8. In the event of a failure, the Department of Family Medicine predoctoral education curriculum committee will review the student’s performance on the examination, OSCE, or clerkship component in question and a determination as to the student’s final grade will be made. All student requests for consideration of grade changes will be reviewed by the FM predoctoral education committee, who will make the final grade determination. Formal requests for review should be done within one week of notification of your clerkship grade.A copy of the JABSOM academic appeals policy and processes may be accessed at:
POLICY ON STUDENT WORKLOAD
The Department of Family Medicine and Community Health recognizes the importance of balancing medical education, patient care and student well-being. To accomplish this goal, we have adopted the provisions set forth by the Accreditation Council for Graduate Medical Education (ACGME) for residency programs nationwide:
· Duty hours are generally limited to a maximum of 80 hours per week (Students may exceed this at their own discretion and with approval of the clerkship coordinator)
· Duty periods cannot last for more than 24 hours, although students may remain on duty for six additional hours to transfer patients, maintain continuity of care or participate in educational activities (i.e. didactics, colloquia, seminars, etc.).
· Students are expected to have one day out of seven free from all clinical and educational responsibilities.
· Students should be given at least 10 hours for rest and
personal activities between daily duty periods and after any in-house
POLICY ON STUDENT MISTREATMENT AND HARASSMENT
The Department of Family Medicine and Community Health will not tolerate any mistreatment or harassment of any individual. Examples of mistreatment or harassment include, but are not limited to:
· Physical punishments or threats
· Sexual harassment
· Discrimination based on race, religion, gender, age, sexual orientation, or physical disability
· Repeated episodes of psychological punishment such as public humiliation or intimidation
· Requiring the performance of personal services
· Taking credit for another individual’s work
If you feel that you are being mistreated or harassed at any point in your clerkship, please notify someone as soon as possible. Please refer to the Unit 6 Handbook’s section on medical student mistreatment for a list of appropriate individuals that you should contact in these cases. Please be assured that all student reports of mistreatment and harassment are protected from retaliation and will be investigated fully. These reports will have no bearing on your clerkship evaluations.
CAREERS IN FAMILY MEDICINE
As part of your clerkship experience in Family Medicine, we would like you to get a good idea of what it is like to be a Family Physician and to explore the possibility of choosing this specialty for your career choice. If you are interested in pursuing a career in Family Medicine, please talk with the Residents and Faculty members who can give you good insight into residency requirements, work opportunities, and lifestyle issues. A wonderful resource to utilize if you are contemplating a career in Family Medicine is the American Academy of Family Physician’s Family Medicine Interest Group website (http://fmignet.aafp.org/). It is filled with numerous student resources that will come in very handy for both your third and fourth year in medical school. The intro to family medicine folder on you CD-ROM also contains articles and information on FM as a specialty. You should also contact either Dr. Jill Omori or Dr. Damon Lee who are career advisors for the department.
To be turned in by student at the end of theclerkship:
Observed H&P checklist (Print it out and fill in throughout clerkship)
Family Medicine Critically Appraised Topic (Print it out to turn in)
Objective Checklist (Print it out and then turn it in)
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Last revised 1/31/11
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