Ambulatory Component of the Internal Medicine Clerkship

Essentials for Students- Visit Notes

Each week, starting with the first week of the clerkship, you must give to your site coordinator or principal preceptor the visit note for a patient you treated as a major provider. These notes should be in the format specified in the prospectus [see section entitled "visit notes"]. Be sure to also give this preceptor the visit note evaluation form. You may expect to receive your annotated note and the completed evaluation form within 48 hours. Your note should be appropriately short (rarely more than two handwritten pages) but complete for the problems identified during the visit. Be sure the review of systems is complete for all problems and that you discuss a differential diagnosis. Justify your diagnosis and plans.

If the notes you write as part of routine care are complete and suitably structured, a copy will suffice for this exercise. Otherwise re-do your official note. If you choose to submit a note on a new patient (complete H&P), it should be as long and detailed as an in-patient admission note.

You will be graded for each note on a scale of outstanding, excellent, very good, satisfactory, and poor. In your final evaluation for the clerkship, we will indicate your average grade, with missing notes graded as “poor”. To receive an "outstanding" grade on any note, you must 1) date the note, 2) follow a SOAP format, 3) clearly indicate a chief complaint, 4) include a complete history for the CC, 5) indicate medications with dosages (unless unavailable), 6) indicate a full pertinent physical examination for the CC, 7) write in succinct, clear prose and avoid obscure abbreviations and symbols, 8) write an assessment that appropriately evaluates clinical evidence to create a sensible differential diagnosis, 9) indicate a plan that is appropriately complete and does not include grossly inappropriate testing or therapy, 10) follow guidelines in prospectus and 11) sign your name clearly or print it. In general, very simple problems (e.g.: routine F/U hypertension) will not warrant an "outstanding" grade unless the clinical evaluation and assessment is extraordinary (and beyond what might be expected for a routine evaluation of the problem).
Sample Visit Notes and Guidelines

Student-Faculty Rounds

1. Overview

At the beginning of each outpatient rotation, you will receive a schedule indicating the date for your student-faculty round. Identify a patient early in your rotation who you and your preceptor believe will be suitable for this exercise. Well before your session, identify a topic related to ambulatory internal medicine care. Topics in disease diagnosis, pahtophysiology, management and prognosis are the most successful. The most important feature of a topic is that it interests you. In preparing your seminar, please keep in mind that small group teaching is usually most fun and successful when the group is asked to solve a problem. Make every effort to encourage participation by your colleagues. If you have never done this sort of thing before, you may want to read about small group teaching (Ch. 3 in reference by Newble). You may want to bring visual aids or assign specific reading to individuals in your group who can become "consultants". Be creative. If your session is loud, fun, and informative, you will have succeeded.

You will turn in to the clerkship coordinator a copy of your written objectives for your seminar and a copy of any handouts or powerpoint slides for your file.

2. Goals and Objectives- Student Faculty Rounds has two objectives:
   1. To broaden the exposure all students have to common conditions in Ambulatory Internal Medicine Care.
   2. To help students develop skills in small-group instruction.
3. Guidelines for your presentation:
   1. Select a patient from your ambulatory experience who illustrates a challenge in diagnosis, prognosis, or disease management.
   2. Design a 30-minute teaching exercise based on this patient or the challenge he/she presents.
   3. Develop and communicate a set of written learning objectives on a behavioral paradigm. In this paradigm, objectives are written in a manner that implies an assessment strategy. For example, instead of writing “describe the shoulder examination”, try “by the end of the session, students will be able to demonstrate an effective examination of the shoulder”.
   4. Keep your exercise narrowly focused. Avoid overviews or large topics. For example, rather than talking about the treatment of pneumonia, talk about risk stratification for patients with pneumonia.
   5. Problem-solving exercises are more effective than lectures for most teaching. For example, for a session on physical examination of the ankle, ask students to examine each other or themselves (rather than lecture on how to examine the ankle). For a session on diagnosis of headache, give a brief lecture on the topic (10 minutes), and then have students work through several cases.
   6. Use stimulus materials (e.g.: cases, a quiz, photographs, data to interpret).
   7. An enthusiastic teacher will create interest in his/her topic more effectively than a teacher who is uninspired. Interest improves motivation to learn.

3. Specific SFR Formats That Have Succeeded In The Past:
   1. Round Robin Problem Solving
      Following a mini-lecture (5 minutes), presenter poses a series of problems that students take turns solving. This format has been used successfully, for example, in helping students diagnose different types of nevi, recognize malignant skin lesions, understand the predictive value of physical examination findings, and interpret ECGs. For the session on recognizing malignant skin lesions, the student projected skin photographs and asked each student in turn to describe them, identify ABCD characteristics ( Asymmetry, Border irregularity, Color variation, Diameter) and recommend for or against biopsy. For the session on predictive value, the student defined the likelihood ratio and demonstrated how it is used to calculate post-test probability. He then presented a series of physical examination maneuvers and administered multiple-choice questions regarding their absolute or comparative likelihood ratios. Many myths were debunked.
   2. Physical Diagnosis
      Following a mini-lecture on the pertinent anatomy or physical examination components, students examine each other. This format has been used successfully to teach the Ottawa Ankle rules and the shoulder exam.
   3. Traditional Lecture
      This is a riskier strategy, but it can succeed when the topic is very circumscribed and the presenter is well-organized. In one successful example, a student projected a list of complications from an undisclosed disease. The complications included gastric perforation, osteoporosis, and sudden death. NO ONE identified the disease (eating disorder). Now motivated, students paid attention to the lecture that followed.
   4. Traditional Case Conference
      In this format, the presenter hands out (or projects) the description of a patient. Members of the audience are asked questions. At points, the presenter fills in the group's knowledge gaps with mini-lectures.
      
      Sometimes a case is used to lead-in to a longer lecture. This format was used successfully by a student who talked about drug interactions of selected herbal remedies.
   5. Quiz Bowls
      In this format, the student presenter introduces his or her topic and then divides the audience into teams. Questions are posed to one team and then the other. This format fails when the questions test factual recall rather than problem solving skill.

Report

During the last three weeks of the rotation, students will meet with an attending physician to review patients encountered at clinical sites. Students will be notified in advance that they will be asked to present a patient; each student will present at least once per rotation.

The format is a traditional report: students present a patient to his or her colleagues. This presentation should be concise and orderly, not exceeding three minutes. The presentation should begin with a clear statement of the chief complaint and proceed in a S.O.A.P. format from HPI to medications to FH to SH to ROS to PE to data to assessments and plan. The attending, who may interrupt the student during his/her presentation, will facilitate a discussion of differential diagnosis, pathophysiology, treatment, practice style, etc. Presenting students should come well prepared with complete information about their patient and the patient's problem. Background reading will be necessary so that the presenting student may be a resource to his or her colleagues during the discussion. You should have a copy of the visit note done for the patient presented at Report, and hand it into the clerkship coordinator for your file. Turn in a note that reflects your best work. It will become part of your "portfolio." It will not actually be graded, but it will become part of your departmental record and used as evidence that you have achieved the objectives of the clerkship. Some students may choose to simply hand in a photocopy of a visit note, others may want to re-type a note. It is up to you.

Self-Directed Learning

You may happily note one major distinction between hospital-based practice and office-based practice: offices generally close in the evening. The evening, however, is when many general internists write notes, make hospital rounds, and do patient-directed reading. Most internists are on call several nights per week. You, too, will probably be writing some notes in the evening and rounding. Generally, however, you will get home for dinner and sleep.

For you, the uncluttered evenings will be a time to read about your patients, research questions that arise during the day, prepare for case conferences, and prepare for student-faculty rounds. Preceptors have been specifically asked to look for evidence that you have read articles and books between clinic sessions. You are encouraged to use the evenings and other free time to build your knowledge of internal medicine and learn from your patients.

The Written Examination

A written examination will be administered as a take home exam the last week of the clerkship. It will comprise about 30-40 multiple-choice questions based on the ethics and case conferences. A few additional questions will be on common or serious conditions not covered in these activities. The exam is offered online through Exam Master. At the beginning of the fourth week, you will receive an e-mail with a link to Exam Master.

This exam has three purposes:

1. to broaden your understanding of the issues in ambulatory care internal medicine
2. to facilitate your assessment of your capability in ambulatory care internal medicine
3. to help the Steering Committee of this clerkship measure and improve the performance of the curriculum

All students must take the examination to receive a passing grade for the clerkship, but no minimum score is required and a student's grade on the examination does not influence his or her overall grade in the clerkship. A student's transcript will reflect whether or not he or she took the examination. The examination score is available on Exam Master and may be used by the student and his or her academic advisors to plan future study and learning priorities. Students who score below the minimum standard set by the steering committee may take the examination again, although this is not required.