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Thomas Jefferson University

Sidney Kimmel Medical College

Department of Family & Community Medicine

Family Medicine
Clerkship Handbook
MS III
2016-2017

Family Medicine Clerkship 1


WELCOME
The Department of Family & Community Medicine of the Sidney Kimmel Medical College at Thomas
Jefferson University welcomes you to the Family Medicine Clerkship. The Family Medicine Clerkship is a
6-week rotation with sites around greater Philadelphia. Contact information for each of these sites is
available on Blackboard.

The following pages are designed to prepare you for the clerkship, provide useful information, and
direct you to resources that will help you prepare for the NBME exam and USMLE Step II.

For any questions about the Clerkship, please contact:

Clerkship Director Vice Chair for Academic Affairs


Fred Markham, MD Christine M. Jerpbak, MD
Fred.Markham@jefferson.edu Christine.Jerpbak@jefferson.edu
215-955-2350 215-955-5338
Assistant Clerkship Director Education Programs Administrator
Marisyl de la Cruz, MD Nirva Belizaire-Nobrun, MPA
Mariasyl.delaCruz@jefferson.edu Nirva.Belizaire-Nobrun@jefferson.edu
215-503-3461 215-955-2362
Program Coordinator
Natalie Nederostek, BA, BSN, RN
Natalie.Nederostek@jefferson.edu
215-955-1372

The Family Medicine Liaisons for the 2016-2017 Academic Year are Kristen Kelly and Philip Walker. They
may be reached at kristen.m.kelly@jefferson.edu and pww001@jefferson.edu.

Family Medicine Clerkship 2


TABLE OF CONTENTS

General Information..................................................................................................................................... 4
Policies and Guidelines ................................................................................................................................. 4
SKMC Honor Code ......................................................................................................................................... 4
Attendance.................................................................................................................................................... 4
Professionalism ............................................................................................................................................. 4
Duty Hour Policy ........................................................................................................................................... 4
Learning Objectives ...................................................................................................................................... 5
Clerkship Structure........................................................................................................................................ 6
Expectations .................................................................................................................................................. 6
Assignments ................................................................................................................................................. 7
Overview ....................................................................................................................................................... 7
PELS ............................................................................................................................................................... 8
EBM ............................................................................................................................................................. 10
OSCE ............................................................................................................................................................ 11
Grading & Evaluation ................................................................................................................................. 12
Feedback ..................................................................................................................................................... 12
NBME Exam ................................................................................................................................................. 13
Resources.................................................................................................................................................... 14

Family Medicine Clerkship 3


POLICIES and GUIDELINES
Students on the Family Medicine Clerkship are expected to adhere to the Sidney Kimmel Medical
College Honor code at all times (excerpted below):
The Honor Code assumes that all faculty, residents, fellows, and students conduct themselves in an ethical
and professional manner. Altruism, accountability, commitment to excellence, duty to serve, honor, integrity
and respect for others are essential characteristics of a physician. In addition, the code is dependent on the
collective desire of all members of the academic community to prevent and deter violations, rather than on
proceedings to impose penalties after violations have occurred. If violations do occur within this system, each
member of the community is expected to support and uphold all aspects of the code.

Attendance
Attendance is mandatory at all clinical and educational activities and supplementary work or additional
clinic time may be assigned to make up for any absence.
Excused absences: If you have an unavoidable conflict (e.g., religious observance), you must inform
Nirva Belizaire-Nobrun prior to the start of the clerkship and submit a completed Clerkship
Request for Excused Absence Form.
Unplanned absences: Unplanned absences will be dealt with on a case-by-case basis. You must notify
Nirva Belizaire-Nobrun immediately.

Professionalism
Conduct in keeping with the Shared Professional Values of Sidney Kimmel Medical College is expected at
all times. These values dictate that,
As a physician or future physician, I recognize the implicit trust placed in me by patients and society.
Therefore, I commit to embodying the highest standards of civility, honesty, and integrity in all aspects of my
personal and professional life. These standards include my interpersonal relationships, my academic pursuits,
and my medical practice. I will strive to communicate sincerely and effectively with my patients and their
families. I will treat everyone compassionately, providing respect and protection of privacy, dignity, and
individuality. As part of the trust that society has placed in me, I will advocate for outstanding patient care. I
will endeavor to work effectively with other members of the health care team to provide the safest and
highest quality patient care.

Examples of unprofessional behavior include texting during lectures, repeated lateness, and
inappropriate communication with patients, preceptors, and staff.
Absences, late assignment submissions, and failure to complete faculty evaluations are also
aspects of professionalism that may negatively impact your grade.

Dress Code
Students are expected to wear professional attire at all times. White coats and name tags must always
be worn. Jeans, athletic wear, and leggings are not acceptable.

Duty Hours
Each student must have no more than 80 hours per week of duty hours, averaged over a four week
period. Duty hours are considered all clinical and academic activities undertaken by students. The full
policy is posted on Blackboard.

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LEARNING OBJECTIVES of the Family Medicine Clerkship

1. Know the basic pathophysiology and clinical presentations of common problems in family medicine,
and apply the knowledge practically in the clinical setting.

2. Learn the diagnosis and management of common acute and chronic problems of patients of all ages
in the ambulatory setting.

3. Identify the role of the family and biological, psychological, social, cultural, and economic factors
which impact on health.

4. Develop an appreciation for the patient in context of the family, being interested in the patient
before the disease.

5. Develop primary care problem-solving skills, including skills in communication, data collection and
recording, physical examination, and use of diagnostic techniques.

6. Develop knowledge and skills in health maintenance and preventive medicine.

7. Develop an awareness of community resources and the use of consultation/referral.

8. Appreciate the role of the primary care physician in the delivery of care to the patient, the family, and
the community.

9. Clarify understanding of Family Medicine, and relationships of Family Medicine with other medical
disciplines.

10. Develop skills needed for cost-effective delivery of care, e.g. time management, prioritization, record
keeping, and follow-up.

11. Apply principles of evidence based medicine to real clinical situations.

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CLERKSHIP STRUCTURE
Caring for patients in an outpatient setting is a central component of Family Medicine. At all clerkship
sites, you will spend a significant portion of your time in an outpatient practice. These sessions will be
supplemented by didactics and community-based experiences in order to expose you to other areas of
Family Medicine. These vary from site to site, but often include spending a day on home visits or in a
nursing home.

Students will be supervised by Family Medicine faculty and upper-year residents at all sites. Specific
clinical assignments will be provided during orientation at each of your sites.

EXPECTATIONS
As a 3rd year medical student, you are now an integral part of the team providing patient care. Your
focus should be on gathering information through the history and physical exam, accurately reporting
that information, providing a differential diagnosis, and prioritizing problems.

Every day, you should ask your preceptor about their expectations for presentations and the overall
structure of patient encounters. All attendings and residents have unique styles and expectations for
student performance and it is your job to adapt accordingly.

As a general guide, patient encounters should always include the following steps:
o Wash your hands
o Introduce yourself to the patient
o Obtain pertinent medical history information
o Perform focused physical exam
o Organize and synthesize patient information
o Prioritize the problem list
o Develop an assessment
o Develop a plan
o Document the above in the EMR and/or on paper as instructed
o Present an organized summary to your preceptor

Family Medicine Clerkship 6


ASSIGNMENT SUMMARY
More details on all assignments can be found on the FAMED 350 Blackboard site

Assignment Description
5 fmCases of your choosing must be completed. Choose cases that address a self-identified
learning gap. Each case will take 1-2 hours.
fmCases When: 1-2 cases per week is suggested.
Due: Last day of the clerkship
Read one article from the posted Treatment Guidelines and complete the corresponding quiz.
Medical Reading the article falls under SKMCs Honor Code.
Letter Where: Blackboard
Due: Last day of the clerkship
This is a tool designed to address patients preventive care needs prior to their office visit. You
Preventive should discuss a completed chart with your preceptor prior to that patients appointment.
When: 5 charts during weeks 1 and 2
Care Chart Due: If youre at an affiliate, leave the completed forms with your preceptor since they are
Review HIPAA protected patient information. If youre at Jefferson, leave the forms in Dr.
Markhams box in the precepting room.
An attending, resident, or fellow must observe you doing all of the following: take a history,
Bedside perform a physical exam, give an oral presentation, and counsel a patient. All parts of the
form dont need to be done at the same time or by the same physician. The observed
Observation encounter doesnt have to be a complete history and physical, but can be part of a focused
& Feedback problem and exam.
Due: Certified on PELS Friday of week 3
This project can be done either individually or as a group. A clinical scenario based on a
Evidenced- patient seen in the office is selected. A clinical question written in the PICO format is then
Based developed. Questions must be emailed to the individuals or groups mentor for approval.
Medicine Students then research the evidence base to develop a list of references and create a critique
(EBM) of those references. Based on the evidence, the implications for the scenario patient are
explored.
Project Due: Friday of Week 3 of the clerkship via submission to Blackboard.
Patient By the middle of the clerkship, all students must have:
Certified that they received mid-term feedback
Encounter
Certified that they have been observed during a patient encounter
Log System By the end of the clerkship, all students must have:
(PELS) A minimum of 100 patients recorded

Family Medicine Clerkship 7


PATIENT ENCOUNTER LOG SYSTEM (PELS)
For all clerkships at SKMC, PELS is how you track the patients, procedures, and conditions you witness.

By the middle of the clerkship, all students must have:


Certified that they received mid-term feedback
Certified that they have been observed during a patient encounter

By the end of the clerkship, all students must have:


A minimum of 100 patients recorded
Reported seeing each of the diagnoses/patients listed below

Category Description Number Category Description Number


I was observed during a patient Patient Education re: Meds, DX
Clerkship encounter 1 Sexually Transmitted Infections
Requirement I was given mid-term feedback 1 Smoking Cessation 3
Counseling
Family Other
Medications Examine Patient with Physical
Social / Cultural Disability
Histories
Smoking Status Prioritize Visit Goals
Substance Use 3 Assess for Depression
Clinical Skills
OB/GYN Assess for Dementia
Sexual Assess readiness for change
History of Abuse Explain Test Results /
Treatment Plan
Environmental
Other
Other
Skin 5 Cardiac diseases/problems 5
Physical Dermatological
Examinations Bone or Joint 4
diseases/problems 3
Breast
Endocrine diseases/problems 5
Pelvic
EENT diseases/problems 5
Rectal Gastrointestinal
Key
Male Genitalia diseases/problems 3
DX/Problems
Mental Status Preventive Medicine 5
Other Musculoskeletal
Cancer Screening 3 diseases/problems 3
Neurological
Contraceptive
Counseling diseases/problems 2
Nutrition/Diet/Exercise 3 Psychiatric diseases/problems 3
Osteoporosis Respiratory diseases/problems 4
Women's Health 4

How to ensure completion of these requirements:


Each clinical encounter must be documented in PELS in order to ensure that you are seeing the
numbers and kinds of patients expected.
Encounters should be entered daily in order to stay on target.

Family Medicine Clerkship 8


What counts for PELS?
What you saw How to record it
RJ is a 55 yo M who presents for a blood pressure check. He was started on Medications
HCTZ 25 mg at his last visit 2 weeks ago (last BP 150/85). He denies any side Hypertension
effects from the medication. Repeat BP today is 135/70. He also requests a Nutrition/diet/exercise
refill on omeprazole, which is working well for his acid reflux. He has been
working on healthy lifestyle changes, current BMI is 35.
MC is an 60 yo healthy F who presents for a health maintenance exam. She Nutrition/diet/exercise
has been working on a healthy diet and exercises 3 times a week. Her last Womens health
mammogram was one year ago, her last pap smear was 5 years ago STIs
(normal, HPV negative), and her last cholesterol panel and glucose a year Preventive medicine
ago were normal. Her last colonoscopy was 10 years ago. Her
immunizations are UTD. You order a mammogram, colonoscopy, lipid panel
and A1c, and perform a pap smear today.

PELS Review:
The Clerkship Coordinator will regularly review your PELS progress. Email notifications will be sent if you
have fewer entries recorded than would be expected by that point during the Clerkship. If you are
concerned that you may not meet the requirement of 100 entries or meet all required targets, please
contact the Clerkship Director and Coordinator immediately.

At the midterm of the Clerkship, PELS entries to date should be reviewed with a faculty member who
you have worked with several times. The Education Programs Administrator will check your PELS at
midterm to ensure you are on track, have received midterm feedback, and were observed during a
patient encounter.

Your 100 PELS entries must be entered before the NBME exam on Friday. Your access to the system will
be suspended that weekend and you wont be able to make additions. Failure to complete your PELS
entries will affect your professionalism grade.

Family Medicine Clerkship 9


FAMILY MEDICINE EVIDENCE-BASED MEDICINE (EBM) PROJECT
Background: Why is this project part of the clerkship?
Physicians face increasing responsibilities to care for patients in an environment of ever-changing
medical practices. Especially as the evidence base changes, you need to know how to find answers to
specific medical questions as new situations arise.

Structure
This project can be done either individually or as a group. All students must decide today which format
to use and the differences between the models are listed below. Groups will be assigned randomly
based on the overall number of students choosing this option with no more than 4 students per group.

Project Components
For this assignment, a clinical scenario based on a patient seen in the office is selected. A clinical
question written in the PICO format is then developed. At this point, questions must be emailed to the
individuals or groups mentor for approval. Students then research the evidence base to develop a list
of references and create a critique of those references. Based on the evidence base, the implications for
the scenario patient are explored.

Final Submissions
All projects are due on Friday of Week 3 of the clerkship via submission to Blackboard. Each project
should be completed using the template posted on Blackboard.

Role of Mentor
Family Medicine attendings and residents are available to answer questions and provide guidance on
selecting a clinical question. Mentors also review final submissions.
Mentors will be listed on Blackboard once all groups are assigned.

Resources
In the EBM folder on Blackboard, there are materials on how to select appropriate articles, examples of
good clinical questions, and the template for final submissions.

Individual Project Requirements Group Project Requirements


Number of articles: Minimum of 4 Number of articles: Minimum of 1 per student
Clinical scenario and question: Based on a patient Clinical scenario and question: Based on a patient
seen in the office one student saw in the office, chosen by the group.
Role of mentor: Available to answer questions Role of mentor: Available to answer questions
Notes: Notes: Issues related to division of work should be
resolved within the group itself.

Grading
Excluding the number of articles reviewed, individual and group submissions will be evaluated by the
same criteria which includes the quality of the question, reference critique, and application of the
evidence base to the scenario patient. As with other assignments, completion and quality of the project
may influence your grade, especially for those students on the borderline between two grades.
Plagiarism will result in failure of the clerkship.

Family Medicine Clerkship 10


OBSERVED STRUCTURED CLINICAL EXAM (OSCE)
Reporting Instructions
The OSCE takes place on the final Thursday of the clerkship in the Clinical Skills Center in Hamilton. All
students have been assigned to a specific time, a schedule of which is posted on Blackboard. Please
arrive 15 minutes prior to your scheduled time for a brief orientation.

Structure
All students will have three encounters each with standardized patients. Each encounter lasts 15
minutes. There is a sheet outside of the room with patient information that is for you to review prior to
entering the room. When five minutes remain, there will be an announcement over the loudspeaker. If
you leave the room with time remaining, you will not be allowed to re-enter. All encounters are
recorded.

Whats Evaluated?
The Family Medicine OSCE is different from other OSCEs you will take in the 3rd year, as there is no
physical exam. Instead, this OSCE focuses on communication and counseling skills. Skills evaluated:

Information Sharing Skills History Taking & Interpersonal Skills


Information Giving: History Taking:
Avoids using jargon Starts with open-ended questions
Explains medical terms used Progresses to specific questions
Solicits questions Does not ask multiple questions
Explains reasons for recommendations Does not ask presumptive/leading questions
Checks understanding of patient/family Does not interrupt patient
Assesses patients willingness to follow recommendations Asks for clarification, if necessary
Assesses patients ability to follow recommendations Appropriately includes patient in interview
Uses logical sequencing of questions
Has clear transitions
Segment summary
Management: Interpersonal Skills:
Explains diagnosis Introduces self
Explains management plan Shakes hands with patient upon entering/leaving
Uses visual reinforcement Calls patient by preferred name
Uses written reinforcement Uses good eye contact
Arranges for follow-up Appropriate open body language, sits down
Outlines reasons for follow-up Appropriate facial expression and tone of voice
Appropriately includes parent/child in explanation Uses silence appropriately
Listens carefully
Reflects/ legitimizes patients feelings or concerns
Offers partnership, support, encouragement/praise

Feedback
Following each encounter, the standardized patient will give you verbal feedback. This feedback is
designed to help you improve your communication skills for future patient encounters.

Grading
The OSCE is scored and students are ranked against their peers during a given block, but the score is not
included in your clinical grade for the clerkship. Students who score poorly will have their recordings
reviewed by the Clerkship Director and may be asked to re-take the OSCE and/or undergo remediation.

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GRADING AND EVALUATION
How are students evaluated in Family Medicine?
The following attributes will be evaluated of students at every site:
Clinical skills: history, physical exam, interviewing skills, rapport with patients and families
Knowledge and understanding of medicine
Interpersonal skills: relations with co-workers, peers, supervisors, etc.
Personal attributes: conscientiousness, motivation, initiative, responsibility, respect for others,
responsiveness to constructive criticism, self-directed learning
Problem-solving skills and clinical judgment
Technical skills
Chart documentation skills
Verbal presentation of clinical data
Organization, efficiency, and time-management
Management skills: patient education, execution of treatment plans, managing adherence issues
Life-long learning skills and use of appropriate resources (including evidence-based medicine)
Professionalism: interactions with faculty and staff; completion of all assignments

Mid-rotation feedback
You are expected to ask your preceptors for mid-rotation feedback.
Ask specific questions such as, How can I improve my presentations? and assess your own
performance first.
o If you do not receive mid-rotation feedback after requesting it, contact Dr. Markham.
o Certifying that you received this feedback is a requirement for PELS.
Students are expected to be active participants in receiving and responding to provided
feedback. Midterm feedback is designed to give you a sense of your progress and to identify
areas of your performance that could be improved.

Topics to Address Notes


Students self-assessment

Feedback on areas of
strength

Feedback on areas for


improvement

Feedback on areas not at


an acceptable level

Family Medicine Clerkship 12


GRADING and EVALUATION
All students receive two grades following the clerkship: the clinical grade and the NBME score. These are
determined and reported separately. Grades will be posted within six weeks of the end of the clerkship.

Clinical grades are based on feedback from attendings and residents who supervised your work. Grades
are also impacted by students professionalism (including completion of faculty evaluations) and
timeliness of all assignments. All submitted evaluations will be reviewed by the Family Medicine
Education Committee for final approval.

Grades are based on the following scale, excerpted from the SKMC clinical evaluation:
Failure Marginal Good Good Good + Excellent High Honors
Expected competence Expected Competence at or
in most areas, some competence above expected
remediation suggested overall level in most areas
Please familiarize yourself with the clinical evaluation (a full copy is on Blackboard) and use it during the
clerkship to ask for feedback on the areas listed.

Concerns about the clinical grade can be addressed with the Clerkship Director. Appointments may be
scheduled starting one week after grades have been posted on Banner.
The purpose of this meeting is to clarify the content of the evaluation and not to change the
grade or the comments in the evaluation.
If a students concerns are not resolved at this meeting, the student should contact his/her
assigned Student Affairs Dean.

The NBME exam covers all material relevant to family medicine.


When: the final Friday of the Clerkship at 8:00am (arrive by 7:55am)
Length: 110 questions, with 2 hours 45 minutes to complete it
Where: JAH, Learning Resource Center
Passing score: Students must receive a 70 on the exam in order to pass

How to Prepare
It is important to begin studying immediately as family medicine is a broad field. Be familiar with all the
pediatric and gynecology problems frequently seen in family medicine. Particular clerkship locations
may not have as many patients suffering from a wide variety of medical problems, making it important
to thoroughly review all of the common diseases. Some of the topics covered are health maintenance,
chronic care, continuity of care, and diagnosis and management of common musculoskeletal problems.

The AAFP offers an online question bank to all students who register with the organization (link below)
that most students have used to prepare. It can take up to a week for accounts to become active- please
register as soon as possible.
Free Student Membership Application:
https://nf.aafp.org/MyAcademy/MembershipApplication/PersonalInformation/Student

The Essentials of Family Medicine (Sloane, 6th edition) and Case Files (Toy, 3rd edition) have also been
used by many students to prepare.

Make-up Exams
Make-up exams and retakes are only offered at pre-determined times. If you anticipate needing a make-
up exam, you must contact Dr. Markham immediately.

Family Medicine Clerkship 13


STUDENT FEEDBACK
During week five, you will be able to access evaluations of the faculty and residents with whom youve
worked via New Innovations. Completion of at least three evaluations is mandatory and your
responses are confidential. All evaluations will be compiled by the Clerkship Coordinator and will not be
shared with any of the people you evaluate until after clinical grades have been posted.

During week six, you will receive an email from the Family Medicine Student Liaisons with a link to a
survey. These responses are anonymous and are used to improve the clerkship for future students. The
survey will take less than 10 minutes to complete.

RESOURCES
1) The American Family Physician has great review articles on many core Family Medicine topics, which
can be found here:
http://www.aafp.org/afp/topicModules/viewAll.htm

2) The University of Michigan Department of Family Medicine presents high-quality modules on a broad
range of clinical topics such as women's health, integrative medicine, clinic procedures but we highly
recommend the musculoskeletal exam modules:
https://sites.google.com/a/umich.edu/fammed-modules/

3) The ePSS is an application designed to help primary care clinicians identify clinical preventive services
based on the U.S. Preventive Services Task Force (USPSTF) recommendations. We recommend
downloading to your mobile device/smart phone:
http://epss.ahrq.gov/PDA/index.jsp

Most Common Visits in the Family Medicine Outpatient Setting


1. Hypertension 11. Hypercholesterolemia
2. URI 12. Rhinitis
3. Physical examination (wellness visit) 13. Back pain
4. Diabetes 14. Obesity
5. Sinusitis 15. Urinary tract infection
6. Bronchitis 16. Pregnancy
7. Degenerative joint disease 17. Headache (includes migraine)
8. Asthma 18. Coronary artery disease
9. Otitis 19. COPD
10. Depression 20. Neck pain

Under General Clerkship Resources on Blackboard, you will find: AAFP common diagnoses in family
medicine, abbreviations/dose designations that should never be used in the medical record, a diabetes
algorithm, information on hand washing, a How to guide on presenting patients, hypertension
management and care guides, and SOAP note guidelines.
Rev. 6/30/16

Family Medicine Clerkship 14

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