The Primary Care Medicine Clerkship

OVERALL CLERKSHIP GOALS and OBJECTIVES

At the end of the Primary Care Ambulatory Medicine Clerkship, the third and fourth-year medical student should have a well-developed foundation of skills, knowledge, and attitudes needed to provide for patients in office settings.

1. Basic Clinical Skills

Goal: You will develop and refine the basic clinical skills required to provide effective and efficient primary care.

Important areas:

  • History and physical examination: obtain a patient's history and physical exam in a logical, organized and thorough manner while adapting to the urgency of the medical situation and the time available.
  • Diagnostic decision making: formulate a differential diagnosis based on the key findings from the history and physical examination.
  • Therapeutic decision making: understand risks, benefits, and compliance issues in choosing a treatment.
  • Procedures: be able to perform such procedures as throat cultures, PAP smears, gram stains, wet mounts, and EKGs.

2. Comprehensive Care of Primary Care Patients

Goal: You will recognize the spectrum of problems that occur in primary care and will understand how to provide, continuous comprehensive care to patients and their families.

Important areas:

  • assessment of undifferentiated presentation, separating those problems that are serious and require immediate evaluation and consultations from those that do not.
  • exposure to extended care centers including community clinics.

3. Communication Skills

Goal: You will develop effective communication skills with patients, families and other health care providers.

  • with patients:

    Identify hidden agendas; recognize psychosocial issues; demonstrate listening skills with probing and clarifying; work with multiproblem patients, angry patients, and somatisizing patients.

  • with colleagues:

    Make concise, accurate, and well-organized clinical notes and oral presentations and write prescriptions.

4. Application of Health Promotion and Disease Prevention Strategies

Goal: You will learn the principles and the application of health promotion, risk factor assessment, and disease prevention interventions. Important areas:

  • screening: criteria for incorporating a screening test and preventive measures routinely addressed in the clinic.
  • risk identification in the medical interview.
  • personal and cultural beliefs that influence patient participation in health promotion.
  • patient education and techniques for counseling toward behavioral change.

5. Bioethics of Care

Goal: You will gain appreciation for the personal, economic, ethical, and legal issues that influence the patient and the physician in primary care.

Important areas:

  • personal: balance in physician's personal life, independent learning and self evaluation.
  • economic: practice management including managed care, billing, insurance, and reimbursement.
  • ethical: advanced directives and informed consent in the office.
  • legal: risk management, including communicating with difficult patients and proper documentation.

6. GUIDELINES FOR STUDENTS WORKING IN OFFICE PRACTICES

  • You are encouraged to participate in all activities of the practice.

    Assume an active, interested role as a partner in the practice as you participate in the office evaluation of patients. Although not required, you may also arrange with your preceptor to take part in administrative planning, hospital rounds, emergency room visits, night call, or home visits of his or her patients.

  • In the office, you are encouraged to work independently as well as observe the preceptor.

    When working independently let the following steps be a guide:

    • see patient alone, introduce yourself, informing the patient that you are a medical student, working with the patient's physician.
    • perform a focused interview and physical examination, formulate a differential diagnosis, and decide on the diagnostic and therapeutic strategies needed.
    • tell the patient that the preceptor will return with you to review the situation.
    • present the patient's history and physical examination, reevaluate the patient with the preceptor.
    • discuss the assessment of the problem and the recommendations with the patient.
    • order appropriate tests and write prescriptions with the preceptor's approval.
    • write or dictate a progress note and have the preceptor approve it.
    • see the patient in follow-up, if possible.
    • pay attention to your schedule and the patient's - try not to keep patients waiting.
    • When observing the preceptor, observe the preceptor's style of interaction and interview techniques.
    • participate in the interview when appropriate.
    • participate in the physical examination with the preceptor.
    • interpret diagnostic tests and formulate treatment plans with the preceptor.
  • You are encouraged to be an independent learner. Get involved in the care of patients and read about the problems that you see.

    Talk with your preceptor about preventive medicine, cost containment, insurance and billing, staff relations, balancing the professional and personal aspects of your life, etc. Do literature searches to help you and your preceptor learn about the case and determine a course of action.

  • For students in pediatrics, below are some further guidelines.

7. GUIDELINES FOR MEDICAL STUDENT EDUCATION IN COMMUNITY BASED PEDIATRIC OFFICES

  • THE GOALS AND OBJECTIVES OF A COMMUNITY BASED CURRICULUM
  • Gaining an understanding of the community based Pediatric practice so that the student can make a knowledgeable career choice.

This understanding requires learning about:

  1. Pediatric manpower needs and health care models such as HMO'S, small and large group practices and PPO'S
  2. Health promotion, disease prevention, child advocacy, child and adolescent behavior and development
  3. Practitioner involvement in medical student and resident education and office-based research
  4. The lifestyle of the practicing pediatrician
  5. The pediatrician's involvement in the community
  6. The characteristics of practice that are professionally rewarding and enjoyable as well as those that are less desirable
  • Gaining an understanding of those professional attitudes that promote good health care practices in primary care settings.
    • These professional attitudes include:
  1. Care that is family-centered, accessible, comprehensive, coordinated and continuous
  2. Cost effective use of laboratory tests and screening methods
  3. The importance of independent lifelong learning that is achieved by primary care providers
  • Acquiring the skills that are effective in time-limited patient encounters.
    • Skills that are needed include:
  1. Utilizing interviewing skills with patients during a focused encounter
  2. Performing a focused physical examination
  3. Learning to collect and synthesize limited data to develop appropriate diagnostic hypotheses and treatment plans
  4. Recording and documenting patient information, diagnoses and treatment plans in a concise, organized manner
  5. Learning about using the telephone as a means of effective counseling, of identifying illness, of initiating treatment and of obtaining follow-up information
  • Acquiring knowledge.
    • The student should learn about:
  1. The pathophysiology, epidemiology and treatment of acute and chronic diseases common to a community-based primary care setting
  2. Methods used to prevent accidents
  3. Methods used in disease prevention, including immunizations and screening tests
  4. Methods used for health promotion, including developmental screening, anticipatory guidance and counseling
  5. Using computers in patient care and office management
  • Developing an introductory understanding of how community resources relate to child development, education and health care.
    • Resources include day care, preschool programs, schooling (including special education), parent support groups, and other community agencies. The observation and evaluation of children at different ages provides a unique opportunity to understand the development of children and how community resources are integrated in the care of children.