Ambulatory Component of the Internal Medicine Clerkship

Learning Objectives

The goal of this course is to provide students with the experiences and teaching required to develop specific competencies for the practice of ambulatory internal medicine and to know the domain of internal medicine within our health care system. By the end of the rotation, all students are expected to achieve nine specific learning objectives. The objectives are based on the SGIM/CDIM monograph, “Core Internal Medicine Clerkship Guide", and the mission statement and school-wide objectives for Yale Medical School.

1. Given an adult patient, an examination room, and twenty minutes, obtain an accurate focused medical history.
   Criteria: By observing the student and speaking with the patient, the preceptor will certify that:
   1. The chief complaint is accurately identified.
   2. The history is obtained in a logical, organized, and thorough manner.
   3. The student demonstrates effective verbal skills, including appropriate use of open- and closed-ended questions, repetition, facilitation, explanation, summation, and interpretation.
   4. The student seeks the patient's point of view.
2. Given an adult patient, an examination room and ten minutes, complete an accurate focused physical examination.
   Criteria: By observing the student and speaking with the patient, the preceptor will certify that:
   1. The physical examination is appropriately focused without incorporation of unnecessary maneuvers or omission of essential maneuvers.
   2. The student's findings are accurate.
   3. The student demonstrates appropriate technique for eliciting all pertinent signs.
3. Given history and physical findings for an adult patient, formulate (describe) the differential diagnosis and a diagnostic plan.
   Criteria: By observing the student and speaking with the patient, the preceptor will certify that:
   1. The differential usually includes the correct diagnosis plus other plausible diagnoses.
   2. The student identifies key economic, clinimetric, and risk features among test options
   3. The student elicits and accounts for the patient's perspective in diagnostic decision making.
4. Having interviewed and examined a patient, make an oral presentation and write a note.
   Criteria: The preceptors will certify that for almost every patient he or she cares for, the student:
   1. Completes the oral presentation in three minutes.
   2. Includes a chronologically-developed present illness, medication list, past history, and pertinent positives and negatives from the family history, social history, and physical examination. Describe the differential diagnosis.
   3. Writes the note in SOAP format according to examples in the course prospectus.
5. For patients you have interviewed, ascertain and interpret the results of common tests.
   Criteria 1: Preceptors will certify that for at least a few patients, the student correctly:
   1. Describes the results of common tests in terms of related pathophysiology.
   2. Describes the meaning of sensitivity, specificity, pre-test probability, and predictive value.
   3. States the post-test probability based on test results.
   4. Anticipates (describes) the implications of test results before ordering tests.
   Criteria 2: For almost every patient you care for, the preceptor will certify that you:
   1. Personally review test results.
6. For patients you care for, develop (describe) and implement appropriate therapeutic plans.
   Criteria: The preceptor will certify that the student can:
   1. Describe key factors to consider in choosing among treatment options, including risks, cost, and efficacy.
   2. Formulate (describe) an initial therapeutic plan.
   3. Write prescriptions accurately.
   4. Monitor response to therapy.
   5. Involve the patient in therapeutic decision making, explaining the risks and benefits of treatment. Demonstrate respect for patients and a commitment to involve him/her as an actual participant in his/her health care.
7. For patients you have cared for, demonstrate the learning skills and ability to identify and meet emerging information needs for diagnosis, prognosis and treatment.
   Criteria: Preceptors will certify that the student can:
   1. Acquire, interpret, and apply information form a diverse array of sources to optimize diagnosis and management of individual patients.
   2. Classify information sources according to broad scientific categories: original research, meta-analysis, structured reviews, narrative reviews.
      
8. In all patient encounters, demonstrate behaviors consistent with the highest standards of professionalism and medical ethics.
   Criteria: Preceptors will certify that the student can:
   1. Describe and implement basic elements of informed consent.
   2. Demonstrate considerations of patients differing perceptions of health and illness as they relate to patient care.
   3. Demonstrate a commitment to caring for all patients regardless of gender, race, socioeconomic status, intellect, sexual orientation, or ability to pay.
9. Demonstrate skills for coordination of care and communication with colleagues.
   Criteria: Preceptors will certify that the student can:
   1. Participate in requesting a consultation and identifying the specific questions to be addressed.
   2. Participate in coordinating care outside the hospital.
   3. Demonstrate an attitude of teamwork and respect towards all members of the health care team as manifested by reliability, responsibility, and honesty.
   4. Demonstrate acceptance of the premises that various physician styles may each be appropriate and that different valid approaches to patient care may coexist.
   5. Work as an effective member of the patient care team.