Preceptor Guide 2000

Table of Contents

Introduction
Site Directors & Coordinators
Course Objectives
        Knowledge
        Skills
        Attitudes
Schedule
Components of the Clerkship
Clinical Sessions
                Clinical Schedule
                Recommendations for interaction with the students
Core Curriculum
               Problem-Based Learning Cases
               Case-Based Discussions
              Didactic Series
               Labs
               Harvey
Faculty Development
Evaluation of Students
Attendence
Preceptor Evaluation
References
Student References

INTRODUCTION

Thank you for participating as a preceptor for the ambulatory internal medicine clerkship at the University of Illinois at Chicago. This rotation is a very important part of the training of our medical students and the success of this course will be due to the dedication and work of the preceptors who have agreed to teach our students the art of ambulatory medicine. This guide is designed to explain the purpose and mechanics of the course and to answer any questions that may arise.

In the event that you have questions that are not answered in this guide, please feel free to call or e-mail us with any queries or concerns regarding the course.

Thank you.

SITE DIRECTORS & COORDINATORS 

Director: Dr. Lee Tai (708) 346-4429
Coordinator: Nedra Cipcich (708) 346-4239

Director: Dr. Marc Fine (847) 723-6464
Coordinator: Kinga Nyckowski (847) 723-6464

Director: Dr. Michael McDonnell
Coordinator: Pat McMullin (312) 567-2167

Director: Dr. Z. Ted Lorenc
Coordinator: Linnea Thennes (815) 759-4206

Director: Dr. Alejandro Aparicio 773-878-7300 x1240
Coordinator: Val David, (773) 279-3153

Director: Dr. Kenneth Grumet
              Dr. Gary Novak
Coordinator:  Barbara Li (847) 316-6228

Director: Dr. Bill Galanter (312) 413-3037, Page #2868
Coordinator: Jennifer Lopez (312) 996-7704

Director: Dr. Bob Molokie (312) 666-2129, Pager 2687    

Students participating in this clerkship will achieve the following competencies:

a. Appreciate the range of illnesses and patient problems seen by general internists in the ambulatory setting.

b. Understand the pathophysiology, diagnostic options, and treatment modalities for the acute, sub-acute and chronic presentations of common medical conditions. These diseases will not be limited to, but will include the most common diseases and symptom complexes encountered in ambulatory Internal Medicine, ex: arthritis, asthma, bronchitis, congestive heart failure, COPD, diabetes mellitus, hypertension, ischemic heart disease, pharyngitis, sinusitis, upper respiratory infections, and urinary tract infections.

c. Define a medical problem and manage it over time in the context of the patient’s other problems, his or her social circumstances, the importance of the problem, and the necessity for diagnosis.

d. Appreciate the need for effective time and cost management in the ambulatory   setting.

e. Effectively incorporate into practice age and gender-appropriate disease prevention and health promotion practices.

f. Appreciate the importance of effective communication skills and the doctor patient relationship in the successful implementation of medical care plans.

The students will have the opportunity to improve their skills in three critical areas: Medical interviewing, focused physical examination, and the use of the medical literature. Specific skills include:
   
    a. Identifying the patient’s agenda and his or her goal in seeking care.

    b. Conducting an efficient interview.

    c. Elucidating the psychosocial factors that affect disease, treatment and patient expectations.

    d. Acquiring effective communication skills.

    e. Conducting an efficient and focused physical examination.

    f. Utilizing principles of evidence based medicine (EBM) and rules of evidence to appropriately      use the medical literature to optimize patient care.

    g.Learning the appropriate utilization of consultation.

The care of patients in the ambulatory setting requires a different perspective than that of the inpatient service. The students will learn the appropriate attitudes necessary for care of the patient in the ambulatory setting. Specific examples include:

1. The patients are freer to choose whether they will cooperate with medical

   advice in the ambulatory setting. The students will appreciate the need to negotiate with patients regarding their care.

2. The causes of patients’ complaints are sometimes uncertain and the students will learn to       accommodate this uncertainty.

    c.   The diagnostic work-up frequently occurs in stages over time. The pace of the work-up            depends upon the seriousness of the potential diagnoses, the utility of diagnosis, patient            cooperation, cost-effectiveness, and the test characteristics of diagnostic modalities.Students             will appreciate these factors which dictate the pace and appropriateness of a diagnostic            work-up.

    d. Primary care physicians accept responsibility for the care of all of their  patient's problems, whether or not they provide the care themselves. Students will learn to become responsible for the entire patient and to use consultation appropriately and responsibly.

The 12-week internal medicine clerkship is divided into a 4-week ambulatory component and an eight-week inpatient component. The ambulatory component has two major elements, the core curriculum and the clinical experience. The core curriculum will occur each Monday of the rotation at the University of Illinois. The clinical experience will occur at a variety of ambulatory sites. All ambulatory component months will start on Monday with the first core curriculum day. The clinical portion of the rotation will be conducted on Tuesdays through Fridays. During the months that include the end of clerkship exam, the students are not required to attend their clinical sites on the last Thursday and Friday. A few times during the year the Tuesday after a Monday holiday will be used as a core curriculum day. The full year’s schedule is shown below:

Clinical Sessions

Each student will spend 4 days a week at their assigned ambulatory site. The assignment of clinics to the students will be determined by the site director. Each student should spend at least 3 half days each week with their primary preceptor. The students are not expected to work weekends or nights, but are welcome to do so if a useful clinical experience is available. Students are encouraged to visit any of their patients who were admitted to the hospital.

Sessions with the primary preceptor are fundamental to the success of the clinical experience for the student. Each preceptor and student will need to develop a slightly different model to accommodate their unique personalities, but there are some general principles, which are likely to improve the experience for both the student and preceptor:

-Communication of expectations: The students should understand the general format for patient visits as well as the expectations for presentation of their patients, write-ups and following up on studies. They should understand their role in the clinic and the relationship that they have in the delivery of care by the preceptor. A vital issue which requires particular attention is the importance of working in a timely manner. Students are generally not accustomed to time constraints in their interaction with patients, so this issue may need to be addressed prior to patient interaction to ensure that the student does not put undue strain on the preceptor’s schedule.

-The student-patient interaction: Students will learn the most and enjoy the rotation more if they are able to see patients initially on their own. The preceptor should introduce the student to the patient and explain to the patient that the student will be seeing the patient first and then the preceptor will come in to see the patient. Presentations in front of the patient are encouraged to promote efficiency and to avoid a complete and tedious repetition of data collection. In addition, these presentations may lead to increased demonstration of physical exam findings. Another benefit is that the patient can hear the presentation and correct any misunderstanding, being certain that the attending understands their complaint.

-Patient follow up: The students are expected to follow up on their patients, taking on the role of a physician. The students should keep track of pending diagnostic studies and may call patients with results (under supervision). If patients get admitted, the students should try when at all possible, to visit them in the hospital. The students should conduct their own follow-up visits for such things as blood pressure checks, diabetic control and acute infections, rather than having the patients seen by a nurse. The students are responsible for reading and performing literature searches as necessitated by patient care and should then report back on their findings. This offers the added bonus to preceptors of updated literature searches and may even save you some time in the amount of literature research that you need to perform for patient care. The students are assigned 2 mandatory searches as described below.

-Literature Search Assignments: The students are to perform 2 mandatory literature search assignments (see Appendix C). These are formal searches where the student, under the supervision of the preceptor, will need to choose a clinical problem, formalize a relevant search question and perform a literature search. The student will then explain the potential impact of their results on the care of the patient. This will be written up on a form (Appendix C) and will include no more than 5 abstracts or papers. The results should be handed in to both the preceptor and to the course coordinator.

-Patient Load: The patient load should start out light until the preceptor can get a feel for the speed and competence of the student. The appropriate number of patients for a student to see in a typical half day of clinic is difficult to gauge, but a good guess may be 2 patients at the beginning, with 3-4 patients by the end of the month, depending on the complexity of the care.

-"Didactic Teaching": A busy clinic is not necessarily the best time for a preceptor to sit down and give a lecture to the student. Teaching will need to be done in small doses when time allows between patients. The most important teaching will be in the explanations of the plan of care and in the demonstration of pertinent physical exam findings. More lengthy discussions may need to occur after clinic has ended, with the students being responsible for keeping track of issues that need to be addressed. Students can be given reading assignments or literature searches to perform, with results to be briefly discussed the following morning. Preceptors can expect that the core curriculum will provide most of the "didactic teaching".

Core Curriculum
Students will return to UIC each Monday for a mandatory weekly core curriculum (schedule). The core curriculum will include the educational elements outlined below.

Many of the commonly seen diagnoses in Internal Medicine present with similar symptomatology. These diseases can be compared and contrasted in the context of a common clinical scenario. Paper cases will unfold in the standard problem-based learning format, requiring the students themselves to define learning agendas and solve problems throughout the course of the case. Each case will require students to use the medical literature to determine the most cost-effective approach to diagnosis and management. Tutorial groups will be facilitated by a General Internist who has been trained in problem-based tutoring. The 2 sessions outlined below:

-Shortness of Breath: This case will be developed to promote an understanding of the differential diagnosis of shortness of breath and the characteristic features of some common causes such as congestive heart failure, pneumonia, asthma and COPD. The initial assessment will be emphasized, with a particular emphasis on the outpatient management of asthma.

-Weight Loss in the Elderly: This case will be developed to promote an understanding of the differential diagnosis of weight loss and the characteristic features of some common causes such as hyperthyroidism, malignancy, depression and others. The initial assessment and management will be emphasized, with a particular emphasis on the outpatient management of depression.

Case-Based Discussions

Actual patients seen by students will be discussed with a faculty preceptor. Students will present patients with defined medical problems in order to further their knowledge about the disease process and/or management. The case discussions will last approximately 30-45 minutes. The following topics will be used as an outline for the types of cases to be discussed;

GERD/Dyspepsia
Chest Pain
Managed Care Issues
Hypertension
Congestive Heart Failure
Diabetes Mellitus
Lower Abdominal Pain
Women's health Issues

Didactic Series

Didactic presentations will emphasize important topics in ambulatory medicine. The format for each session will be faculty dependent, but interactive elements will be strongly encouraged. A list of possible sessions includes:

Asthma
Diabetes Mellitus
Hypertension
Medical Ethics & Managed Care
Preventive Medicine
Women’s Health

Students will get hands-on experience with procedures common to the practice of Internal Medicine, including:

Pulmonary Function Testing; performance, indications and interpretation
Treadmill Stress Testing; performance, indications and interpretation
Internet Based Literature Searches; introduction and examples of using resources such as PubMed, Ovid and Grateful Med

Students will receive a course on the cardiac physical exam using a cardiovascular mannequin called Harvey at the University of Illinois. Harvey is a life size Cardiology Patient Simulator (CPS). Harvey is able to simulate twenty-seven different cardiovascular diseases. Variations in blood pressure, jugular venous pulses, carotid pulses, peripheral arterial pulses, and precordial evaluation may be assessed. Additionally, cardiac auscultation in the four primary auscultatory areas using infrared sound systems may be conducted. Harvey is taught by Dr. George Kondos. For more information regarding Harvey feel free to contact  Ms. Cathy  Vanerka  or Dr. Kondos (312) 996-9347.

Teaching workshops are available to assist faculty in their roles as preceptors. Dr. Mark Gelula from the University of Illinois at Chicago Department of Medical Education and Dr. Galanter will coordinate the workshops. The exact dates of these workshops will be forwarded to all preceptors when they become available. They can also be found by calling the site directors or the course director or coordinator. These workshops are recommended, but not required.

Students will be graded using the usual University of Illinois clinical rotation grading scheme of Outstanding, Advanced, Proficient or Needs Remediation for the entire 12-week Rotation. The ambulatory course will be included as a portion of the clinical grade, which is 2/3 of the whole clerkship grade. The remaining 1/3 of the clerkship grade will be dependent on the end-of-clerkship exam. The ambulatory grade will be a combination of the preceptor evaluations and the core curriculum evaluations. Attendance will be required at all core curriculum and clinical sessions and poor attendance will be counted against the students in the evaluation of their professional behavior.

Preceptors should evaluate students in the areas of history taking, physical examination, problem list formulation, disease management skills, preventative care, communication with patients, note writing, relationship with patients, relationship with the staff, professional behavior and educational initiative. In addition, a written statement of student strengths and weaknesses will be requested. The evaluation form is shown in Appendix A. Evaluation from preceptors other than the students primary preceptor can be given to the students for the purpose of criticism and will be included in their final evaluation, but are not required.

Students are expected to attend all clinics assigned to them. Any absence must be pre-arranged with their preceptors. The course coordinator should be notified about any unexplained absence. Attendance should be included in the evaluation of professional behavior.

All students will be required to evaluate their primary preceptor as well as their ambulatory site. These evaluations can be made anonymously if the student chooses to do so. A summary of these evaluations will be made available to the site directors periodically. A copy of the preceptor and site evaluations are shown in Appendix B.

The effect of intensive treatment of diabetes on the development of long-term complications in insulin dependent diabetes mellitus (DCCT). N Engl J Med. 1993;329:977-86.

UK Prospective Diabetes Study Group: Effect of intensive blood-glucose control with metformin on complications in over-weight patients with type 2 diabetes (UKPDS 34). Lancet 352:854-865, 1998

General Ambulatory Medicine

Smoking Cessation. Clinical Practice Guideline #18. AHCPR Publication No. 96-0692. April 1996.

The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. @Arch Intern Med. 1997; 157:2413-2444. Outline Form

Hansson L, et al. Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial. Lancet. 1999 Feb 20;353(9153):611-6.

Hansson L, Zanchetti A, Carruthers SG, et al, for the HOT Study Group. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998; 351: 1755-62

Obesity

NIH Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults 99'

Preventive Medicine

Hardcastle JD, Chamberlain JO, Robinson MH. Moss SM, Amar SS, Balfour TW, et al. Randomised controlled trial of fecal-occult-blood screening for colorectal cancer. Lancet, 1996;348:1472-7.

Women’s Health

Grodstein, F et al.. Postmenopausal Hormone Therapy and Mortality, N Engl J Med, 1997; 336(25):1769-1775

Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, Vittinghoff E, for the Heart and Estrogen/progestin Replacement Study (HERS) Research Group. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA. 1998;280:605-613.