INTERNAL MEDICINEINTERNAL MEDICINE CLERKSHIPCLERKSHIP

2009 2009

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INTERNAL MEDICINEINTERNAL MEDICINE CLERKSHIPCLERKSHIP

The practice of medicine is an art, not a trade; a calling,The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will benot a business; a calling in which your heart will be

exercised equally with your head.exercised equally with your head.-William Osler-William Osler

Table of Contents

I. Fundamentals (overall objectives) …………………………………………………… 3II. Clerkship Basic Framework ……………………………………………………….... 4III. Daily Clinical Responsibilities …… ………………………………………..……... 5

1. Seeing your patient ……..…………………………………………………. 52. Daily Data Collection ……………………..………………………………… 53. Daily Patient Notes (SOAP notes) …………………………………………. 64. Daily Oral Presentations …………………………………………………… 65. Daily Patient Work …………………………………………………………. 76. Clerkship typical weekday daily schedule .……………………………….. 7

IV. Taking Call ……...…………………………………………………………………. 81. Responsibilities ……………………………………………………………… 82. History and Physicals (How to)……………..........................……………… 93. Typical schedule for a call day …………………………………………….. 11

V. Curriculum ………………………………………………………………………….. 121. Afternoon Report …………………………………………….…………….. 122. Grand Rounds ……………………………………………….…………….. 123. Clerkship School …………………………………………..………………… 124. EKG Lecture ……………………………………………………………….. 125. Shelf Review ……………………..………………………………………….. 13

VI. Assessment and Testing …………………………………………………………… 131. Observation Worksheets …………………………………………………… 132. History and Physical Evaluation ………………………………………….. 133. Student Presentations on an IM topic……………………………………… 134. Mid-Block Feedback ………………………………………………………… 135. Practical Exam …..………………………………………………………. 146. Shelf Exam …………………………………………………………………… 147. Ward Evaluations ……………………………………………………………. 158. Professionalism ………………………………………………………………. 15

VII. Grading ..…………………………………………………………………………….. 161. Honors ………………………………………………………………………. 162. High Pass ……………………………………………………………………. 163. Pass ………………………………………………………………………….. 165. Borderline Grade …………………………………………………………… 176. Condition Grade …………………………………………………………….. 177. Failure ……………………………………………………………………….. 178. Grade Breakdown ……………………………………………………….. 17

VII. Books ……………………………………………………………………………… 18VIII. Food and Bags …………………………………………………………………. 18IX. Dress Code ………………………………………………………………………….. 19X. Hygiene ……………………………………………………………………………….. 19

****** XI. Days Off …………………………………………………………………………….. 19****** XII. Absences …………………………………………………………………………… 19

XIII. End of the Clerkship Checklist ..………………………………………………… 20XIV. Potential Student Pitfalls ………………………………………………………… 21

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INTERNALINTERNAL

MEDICINE MEDICINE CLERKSHIP CLERKSHIP 20152015

I. Fundamentals (overall objectives). To be an outstanding student and future physician, you must be able to

1. Take an accurate history and perform a thorough physical exam. Understand the importance of making clinical decisions based upon accurate and complete information.

2. Organize your notes, patient information, and data. You must be able to access them readily on rounds. You should track your patient’s data so that you notice trends and can intervene as necessary.

3. Communicate your findings effectively through daily progress notes and oral presentations.

4. Interpret patient data to devise an appropriate diagnosis and treatment plan. Use logic, clinical judgment, and evidence-based medicine. You must be able to devise a plan to treat the patient’s acute issues and work-up the differential in a manner that does not include unnecessary tests and procedures.

5. Behave in a professional manner at all times. In particular, interact in a respectful manner with your colleagues, nurses, and hospital support staff. Be on time. Communicate with your team. Be honest. Take pride in your work and the ideals you represent as members of this profession.

6. Accept constructive criticism, acknowledge errors, flaws in reasoning, and take the appropriate action to remedy the problems. Understand that this is how doctors in training become better doctors.

7. Demonstrate the ability to read and learn on your own. You must be able to apply this newly learned information to the clinical context of your patient.

8. Be an active and integral member of a team.

9. Keep your patient as a priority and always respect his or her autonomy.

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10. Leave some time for yourself. Because of the heavy workload, it is even more important to care for yourself. Understand that life outside the hospital affects your clinical performance and vice versa.

II. Clerkship Basic Framework (The nuts and bolts)

1. The entire rotation is an inpatient rotation. In other words, all patients seen will be hospitalized patients or patients being evaluated for hospitalization. Students will spend their time at either Tulane University Hospital or the Medical Center of Louisiana-New Orleans (University Hospital) or both. The Veterans Hospital service is contained within the Tulane University Hospital until the new VA hospital is built. Students will spend 6 weeks on a general internal medicine hospitalist service and 2 weeks on a subspecialty consulting service, either cardiology, hematology/oncology, gastroenterology, infectious disease, or nephrology.

*** For General Internal Medicine Hospitalist Teams***

2. Each hospitalist ward team is comprised of interns, residents, and an attending.

3. Students are expected to see patients everyday and present their patients on rounds. Students should go over patients with their resident before attending rounds. At Tulane, MCLNO, or the VA, students should present their patients to their residents during resident rounds. Resident rounds typically take place at 8:00 AM.

4. Students will take call with their team. At Tulane, MCLNO, and the VA, call is usually every fourth night. Students do not take overnight call and should be dismissed by 10:00 PM.

5. Students should attend Grand Rounds and Afternoon Report with their ward

teams, unless the time conflicts with mandatory curriculum obligations.

***For Subspecialty Teams***

6. Subspecialty teams will be comprised of an attending and a fellow. There may be residents and interns also on the team, but this may be variable depending on the subspecialty service and availability of residents and interns. Please contact your fellow when beginning your rotation on a subspecialty service.

7. Subspecialty services receive new consults everyday. You do not officially “take call” with the subspecialty services. Rounding times will be dependent on the service and the fellow.

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8. You are expected to attend Grand Rounds with your team. You are NOT expected to attend afternoon report while on a subspecialty service.

9. Students are expected to observe their colleagues performing H&Ps and complete worksheets based upon their observations. Students will need to complete 2 worksheets on the history of present illness (HPI), 2 worksheets on the 2nd paragraph of the HPI and Past Medical History, 2 worksheets on the physical exam, and 2 worksheets on the assessment and plan. Please turn these into Leigh-Ann in the Student Programs Office. See “worksheets” for more details.

***For All Teams***

10. Students are to help their team with ward work during the day unless they have mandatory curriculum obligations (Clerkship School, EKG lecture, Shelf Review,) or their resident or fellow dismisses them.

11. Students will turn in copies of their History and Physical Exams to their attendings for evaluation. Two perfect scores on two separate H&Ps are required for passing the clerkship. Please give H&Ps only to attendings on the general internal medicine services. Do NOT give H&Ps to attendings on subspecialty services. Please turn these into Leigh-Ann in the Student Programs Office. See “History and Physicals” for more details.

12. Students will choose two topics during the eight weeks and teach their team about them in a 10-15 minute presentation. Attendings will grade the students’ performance. The grade sheet and a single page summary of the presentation should be turned-in to Leigh-Ann in the Student Programs Office. See “Student Presentation on an IM topic” for more details. This may be done on either the general internal medicine services or subspecialty services.

13. Students will need to keep track of the types of patients seen throughout the clerkship. All encounters must be entered into E-value. This is extremely important because it is necessary for the accreditation of the medical school.

14. After three to four weeks on the rotation, each student will need to complete a self-assessment of his or her performance on the wards.

15. After completing the self-assessment, each student will obtain feedback from his or her attending and meet with Dr. Miller to discuss.

16. A practical exam, including EKGs, and clinical problem solving will be administered at the end of the block.

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17. The majority of the clerkship grade will be comprised of the ward evaluations by attending, fellows, and residents.

18. A shelf exam, written by the NBME (National Board of Medical Examiners), will be administered on the last day of the clerkship (Friday) at 8:30 AM. It will be electronic. Location is scheduled to be in room 5001 in the Med School building (1430 Tulane Ave).

III. Daily Clinical Responsibilities.

1. See your patient and perform a physical exam everyday. Ideally, you should be seeing at least two patients a day, but no more than four. Ask how they’re doing. Ask about his or her night. Ask relevant questions regarding his or her reason for being in the hospital (i.e. Is your chest pain better? Did you have a bowel movement? Are you still vomiting?). Make sure you note any changes in condition from the previous day, better or worse. Perform a focused physical exam. You are expected to focus your exam only after you have completed a total physical exam at the time of admission.

2. Collect relevant data from the chart, computer, and nurses. Get the vitals, accuchecks, ins and outs, daily weight (if applicable), etc. from the chart. Read the nurse’s notes in the chart. Read any consultant’s notes from the prior day. If your patient has a cardiac monitor on, do not forget to check the overnight telemetry readings! This will be in the chart as well as the telemetry room. Talk to your resident for specific locations at each hospital. Get the labs from the computer system as well as the results of any important radiologic studies or procedures. This may require you to go to radiology to get the preliminary read or have a Radiologist read the study for you right at that moment. Find the patient’s nurse and obtain any relevant information to the patient’s night and current condition. Sometimes, there is very important information that gets passed between the nurses that does not make it into the chart.

3. Daily patient notes. You must write a daily note on each of your patients. The note should be titled: T-3 Internal Medicine Progress Note. All notes MUST BE PROPERLY DATED AND TIMED!!!. Simply put the date and time in the left margin at the beginning of your note. This note must be co-signed by your intern, resident, or fellow. Each note should contain the following:

Subjective: What happened to the patient overnight? How does the patient say he or she is doing this morning relative to

their clinical problem? Are there any new complaints?

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Objective: Always put the vital signs next, followed by the physical exam, and then labs and studies. Current medications and dosages

should be listed along the left margin of paper notes for easy reference. Electronic notes will have the medications listed in the body the note.

Assessment: This should be what you are thinking about the patient’s condition. This should be the synthesis of important

information to arrive at a conclusion as to the patient’s main diagnoses and main problems. Pertinent questions to guide you might be, what is the patient’s clinical trajectory? Is the patient getting better or worse? Are you closer to a diagnosis (if previously unknown)? Is your diagnosis incorrect? Are there new findings that need to be addressed?

Plan: This is what you are going to do. It should be organized into a problem list. The first problem should always be the most

serious or the reason why the patient is admitted to the hospital. The plan for each problem might include further tests and studies you wish to order, adjustments in medications, or other changes in management (i.e. will consult surgery for acute appendicitis).

***NEVER should a student note say, “will discuss with team.”***

***Student notes should be completed before attending rounds.***

4. Daily oral presentation on rounds. Anytime you see a patient and write a patient note, you should present this same patient on rounds. This does not mean reading off of your SOAP note. The information presented should be organized similar to the SOAP note (i.e. first the subjective, then objective, then assessment and plan). You do not need to state when you are transitioning from subjective to objective or to the assessment and plan. It will be obvious to all listeners. The best presentations are done without notes and done in a fluid manner. You should be able to look your teammates in the eye while you present. It should not be loaded with extraneous information, but include all the relevant information (this is the hardest part to learn, so don’t sweat it if you include some unnecessary stuff early on in the clerkship). Always attempt to discuss your patient with intern or resident during pre-rounds. This will help you jettison the extra information and focus on the important stuff.

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***Interns, residents, or fellows should not repeatedly interrupt your presentations. Expect them to augment your presentations at

the end, especially early in the year. If this becomes a problem, let Dr. Miller know***

5. Daily patient work. This is the stuff that needs to get done to advance the care of the patient. This is variable, but common tasks include ordering labs and studies, calling consultants, following up on labs or tests that were not completed by attending rounds, and completing paperwork for discharge, nursing home placement, etc. Sometimes this stuff gets labeled as scutwork. Yeah, it may be some of the less glamorous stuff, but it has to get done. You are expected to help in these tasks, but these assignments should not be overbearing. Remember, these seemingly menial tasks are essential to getting the proper care for your patient. I promise you that the more you invest in your entire team, the more you will get out of the clerkship.

6. Typical Weekday Daily Schedule for Hospitalist Teams

Tulane, VA, and University – Monday through Thursday

6:30 AM – 8:00 AM Pre-rounds – see your patient, collect patient data, write note.8:00 AM – 10:00 AM Resident rounds – present patients to resident, make clinical

decisions, complete morning ward work. 10:00 AM – 12:30 PM Attending rounds – present patients to attending, make

additional clinical decisions.12:30 PM – 3:00 PM Ward work – finish orders, finish discharges, track down

studies and follow-up labs, etc.3:00 PM – 4:00 PM Afternoon Report – meet at designated report room4:00 PM – 4:30 PM Checkout – tie up loose ends and check out to on-call team.

***If your residents are not having Resident Rounds, please let Dr. Miller know. Your attendings expect that you have properly rounded with your resident before presenting to them****

***Please note that weekend days do not include Afternoon Report. Resident rounds may be shortened and attending rounds may take place at a different time. You will need to adjust your pre-rounds accordingly***

IV. Taking Call

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1. On-call responsibilities. If you are assigned to the VA, Tulane, or University Hospital, you will be on-call every 4th night. You are expected to arrive on your call day at 8:00 AM and stay until 10:00 PM, unless your resident sends you home sooner. You should see a minimum of one new patient each call and perform a complete history and physical. You should dedicate a large amount of effort into getting your history and physical in order. Once each student on a team has completed one H & P, you are strongly encouraged to see additional patients and perform additional H & P’s. You are expected to examine, discuss, and take part in the care of other patients the team admits that you have not written an H & P. You are expected to share your interesting findings and patients with your fellow students. Teach them about your patients. On the post-call day, you are expected to stay on the wards helping your team until your team goes home or your resident dismisses you. It there are mandatory curricular activities that day such as Tuesday School, EKG lecture, or Harvey, you are required to leave the wards to attend these activities. Students should remain in professional attire. NO SCRUBS or Sneakers.

***Occasionally, you may have a call night and not receive a patient. Unfortunately, a significant number of patients are admitted

after 10:00 PM. You are expected to then assume the care of one of the new patients the next day after rounds***

2. History and Physicals – these should be comprehensive when written, but only the relevant information should be presented on attending rounds. In other words, you may have to leave out some information that you have collected because the information is not important to the patient’s case.

H & P organization:

Chief Complaint: Do not forget this!!!!

1st Paragraph: Characterization of the chief complaint (FAR COLDER). Once you have gotten all the information necessary to properly

characterize the chief complaint, you need to develop a differential of five possible diagnoses. You don’t have to write these down, but you may want to put them in the margins just to keep you honest in the beginning.

2nd Paragraph: Ask the patient questions relevant to your five potential diagnoses that were not covered by FAR COLDER. The answers

to these questions should make up the second paragraph.

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Review of Systems: This should be comprehensive from head to toe, but only include pertinent positives or negatives in your oral

presentation.

Past Medical History: List any diagnosis they have been given or any diagnoses for which they have been treated. Try to list the year of

diagnosis, if possible. This gives insight into complications that we might expect with a long, chronic disease history versus a relatively new diagnosis.

Past Surgical History: List any surgical procedures. If recent, try to get month and year of the surgery. Otherwise, the year will suffice.

Family History: Make sure you probe deeply if you are considering an unusual disease (especially autoimmune) or an early presentation

of a common disease, such as heart disease or cancer. Deaths of family members at a young age from medical illnesses are usually very

relevant so make sure you don’t miss them.

Social History: Include occupational history, living situation (i.e. alone? With wife and kids? Homeless?). Include habits such as tobacco

use, alcohol use, and recreational drug use. Include a detailed sexual history here.

Allergies: Make sure you note the reaction associated with the allergy… hives? Angioedema? Bronchospasm (Asthma)? etc.

Medications: List all medications. Make sure you include dosages and frequency. Make sure you reconcile the medication list with the

past medical and past surgical history. Each medication should correlate to a diagnosis or procedure already listed. Otherwise, it should be purely preventative (Aspirin, vitamin, etc). If there are orphan medications, meds without clear indications, you need to question your patient about these. If you do not get a satisfying answer, you should consult old medical records.

Vitals: The vitals should always come before the physical exam. You should always present the vitals, even if they are normal. Get the

first vitals taken at triage. You may have additional vitals for your attending, especially if they have changed between triage and the time you actually examined the patient (frequently the ER will have intervened and the dramatic vitals upon presentation may be tempered by whatever therapy was given by the ER docs).

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Physical Exam: Be thorough! Report what you find. Just because the intern or resident did not hear or did not find the same thing as you

does not inherently mean you are incorrect. Remember some findings are intermittent (pericardial rub, for instance).

Labs/studies/radiology reports/etc: Keep this section neat and organized so that information is easy to access.

Assessment: The first sentence should state your working diagnosis. This is your hypothesis. The rest of the assessment should be the

reasoning you used to come to your diagnosis and refute the other four diagnoses you considered in your differential. Make sure you choose a diagnosis and defend it! It is okay to be wrong. Sometimes we learn more by proving a hypothesis as false. You will lose far more favor with your team if you do not try to diagnose the patient and simply defer to them.

Plan: This should be organized into problems/diagnoses. The most important/serious problem should be listed first (i.e. ST-elevation

MI, not toenail fungus). After you list each problem, state what you are going to do to treat the problem and/or further work-up the problem if the diagnosis remains unclear. If the patient is particularly complicated, it may benefit you to have a systems based plan. After you give your global assessment of the patient’s main problem (in the assessment), you list each organ system (neurologic, cardiovascular, pulmonary, etc) and write a brief assessment followed by what you are going to do to either improve that organ system’s function (i.e. increase the oxygen) or what tests you will order to further assess the patient’s problems.

***You will need to turn in two written H&P’s with perfect scores to pass the clerkship. The H&P’s should be a copy of the original form. Do not research and cite articles. We want to see your raw clinical reasoning in each H&P. Do not wait until the end of the block to turn in your H&P’s to your attending!!! Be proactive and turn them in early on so you can get adequate feedback. You must provide your attending with a grade sheet for each H&P. Your attending should return the grade sheet to you and then you should return the grade sheet and H&P (if and only if the score is perfect) to Leigh-Ann Sallis in the Student Programs Office on the 8th floor of 1555 Poydras. Once you have completed two H&P’s with perfect scores, you will no longer need to continue to submit them for evaluation to your attending***

3. Consults (subspecialty services)

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Initial consult notes (the first time you see the patient), should assume the format of the H&P. Daily consult notes after you have seen the patient once should assume the format of the SOAP Note. The key difference on a subspecialty consult service is that you are to focus on the reason you were consulted. You are not responsible for all of the patient’s problems. It is the responsibility of the primary team to make sure all problems are appropriately addressed. For example, if a 65 year-old man is admitted with a COPD exacerbation, but you are consulted on the cardiology service for a single bout of chest pain 2 days into his hospital stay, your focus is on the chest pain and it will take priority in your note. Include details about everything else that is being done for the patient, including the COPD, but these are secondary priorities for the consulting service.

4. Typical Schedule for a weekday call day. The following schedule is for Tulane, MCLNO, and VA General Medicine Hospitalist Teams.

7:00 AM – 8:00 AM Pre-rounds8:00 AM – 10:00 AM Resident Rounds with Intern/Admit patients/Ward work10:00 AM – 12:00 PM Attending Rounds12:00 PM – 3:00 PM Admit patients/Ward work3:00 PM – 4:00 PM Afternoon Report4:00 PM – 10:00 PM Ward work/Admit patients - ***many attendings will have

evening rounds on newly admitted patients***Post call day7:00 AM – 8:00 AM Pre-rounds/mini-Resident rounds (resident rounds are

usually abbreviated post-call because of time issues) 8:00 AM – 12:00 PM Attending rounds (most attendings finish before 12:00 PM)12:00 PM – 3:00 PM Ward work and checkout (residents and interns must leave

the hospital by 2:00 PM).

***Weekend call days will vary by attending, but there will be no afternoon report. Some attendings may simply round once in the afternoon or evening on old and newly admitted patients***

V. Curriculum

1. Afternoon Report – this occurs Tuesday and Thursday, at UH, VA, and Tulane. UH afternoon report takes place in the 5th floor conference room at UH at 2:00 PM. VA and Tulane morning report takes place in Room 1114 on the 1st floor of Tulane Hospital. Wednesday is ICU Report and will take place after Grand Rounds in Room 7062. Please do not be late.

2. Grand Rounds - this occurs Wednesday at 12:00 PM in room 7062 in 1430 Tulane Avenue. There should be a sign-in sheet at the front. Students should attend Grand Rounds with their team. If the team is late, students will not be held

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accountable. It is the resident’s responsibility to get the team to Grand Rounds on time, but if your team is at Grand Rounds, you should be as well

3. Clerkship School – this occurs Monday or Friday Afternoons in the 8th floor Student Classroom (Rm. 808) at 1555 Poydras from 1:30 PM to 4:30 PM. You will sit in your assigned firm (red, blue, yellow, green, orange) and work together on the clinical cases for the day. Each Clerkship School will have a dedicated subject (i.e. Infectious Disease, Cardiology, etc) so that you may read before attending. Bring any resources you want. You may also bring lunch and snacks if you wish. Please clean up after yourself and be on time. Mandatory – this trumps all other clinical responsibilities and you are expected be present even post-call.

4. EKG Lectures – Dr. LeDoux will be giving EKG lectures on Wednesday afternoons in room 808. This will take place during most weeks of the clerkship, but be prepared for a cancellation or a couple of weeks without lecture. Mandatory – this trumps all other clinical responsibilities and you are expected to be present, even post-call.

5. Shelf Review – this is preparation for the NBME shelf exam. The shelf review will be held on the Monday afternoon of the last week of the block in room 808 at 1555 Poydras.

VI. Assessment and Testing

1. Observation Worksheets – You are expected to observe your colleagues take an H&P and give them feedback. If you are the sole student on the VA team, you may observe your colleagues on the Tulane Team who are on the same call schedule as you. More than one student may observe the same student take the H&P.

There are 4 forms (HPI, 2nd paragraph and PMH, Physical Exam, and A&P) that will be used to guide your observation. You should complete only one form per patient, but you must complete 2 of each form before the end of the block. Please go in order, first HPI, then 2nd paragraph and PMH, then Physical Exam, then A&P. Complete no more than two forms per call (this is to ensure you have time for other requirements while on call). The forms can be found on the TMedWeb Clerkship website.

2. History and Physical Evaluation– this is a full H&P that you personally completed on your patient. Please turn in the H&P and the H&P grade form to your attending for him or her to grade. Two H&P’s with perfect scores should be submitted to Leigh-Ann before the Friday of the sixth week of the

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clerkship. It is STRONGLY recommended that this is done as early as possible in the clerkship so that you receive appropriate feedback. These must be turned in to pass the clerkship. The grade sheets are in the orientation packet, but may also be downloaded from the TMedWeb Clerkship website. Please give these only to attendings on the Hospitalist Teams. Do NOT give these to attendings on subspecialty teams.

3. Student Presentations on IM topic – you should complete one presentation each half of the clerkship for a total of two. These presentations should be comprised of a narrow medical topic relating to one of your patients. You should develop a single page summary of your topic, but your presentation should be oral and last approximately 10-15 minutes. You need to cite at least three sources. Two should be recent journal articles. Do NOT cite the online source, Up-to-Date. Give your attending a grade sheet for your presentation. He or she should return it to you and then you should deliver it, plus your single page summary, to Leigh-Ann in the Student Programs Office. The grade sheets are in the orientation packet, but may also be downloaded from the TMedWeb Clerkship website. You may do your presentation at any time during the block and on any service (hospitalist or subspecialty).

4. Mid-Block Feedback – at the third or fourth Clerkship School of the block,

you will be given a self-assessment form to complete. You will turn this into Dr. Miller to be later discussed at a meeting with him. You will take the faculty mid-block feedback form to your attending to have him or her complete as soon as possible. You are responsible for ensuring that the attending completes this form before you meet with Dr. Miller. If the attending has spent less than two weeks with you, consider having the resident complete the form if he or she has spent more time with you. If you are to switch hospitals after the first two or three weeks into the clerkship, it is your responsibility that the attending completes this form before you change hospitals.

5. Practical Exam– this will take place during the last week of the clerkship. This exam will be comprised of EKGs and clinical problem solving exercises. The EKG portion of the exam is multiple choice and based upon Dr. LeDoux’s EKG lectures. The clinical problem-solving portion is multiple choice and free text. It will be based upon a list of 15 key complaints for which you must have an approach. See the document regarding the clinical problem-solving exam.

6. Shelf Exam - this will take place on the last Friday of the clerkship. This exam is comprised of approximately 100 multiple-choice questions made by the NBME (National Board of Medical Examiners). To pass the clerkship you MUST score above the 5th percentile. Scoring below this percentile will result in a condition grade for the clerkship and you will have to retake the exam.

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The Distribution of Content on the Shelf Exam is the following:

I. General Principles 1-5%II. Organ Systems

1. Immunologic Disorders 5-10%2. Diseases of the Blood and Blood-forming Organs 5-10%3. Diseases of the Nervous System and Special Senses 5-10%4. Cardiovascular Disorders 15-20%5. Diseases of the Respiratory System 15-20%6. Nutritional and Digestive Disorders 10-15%7. Gynecologic Disorders 1-5%8. Renal, Urinary, and Male Reproductive System 10-15%9. Disorders of the Skin and Subcutaneous Tissues 5-10%10. Diseases of the Musculoskeletal System and

Connective Tissue 5-10%11. Endocrine and Metabolic Disorders 5-10%

III. Physician Tasks1. Promoting Health and Health Maintenance 10-15%2. Understanding Mechanisms of Disease 20-25%3. Establishing a Diagnosis 40-45%4. Applying Principles of Management 20-25%

7. Ward Evaluations – anytime you have been on a team more than a week and the teams switch, you will be evaluated. You will be evaluated by whatever team you are on during the last week of the clerkship. For most students, this will result in either 2 or 3 total evaluations for the 8 weeks. The attendings, residents, and interns will evaluate each student together and complete a consensus evaluation. Students will be evaluated on the following 6 categories (ACGME Core Competencies):

1. Patient Care2. Medical Knowledge3. Practice-Based Learning and Improvement4. Interpersonal and Communication Skills5. Professionalism6. Systems-Based Practice

7. Professionalism - each student will be given an overall professionalism score that will comprise 5% of the final grade. The final professionalism score will be assigned by the educational committee, but will be based upon the following that are not evaluated in other places: 1. Proper communication of absences/days off to the student programs coordinator. 2. Being on time for Clerkship school, EKG lecture, etc. 3. Strong work ethic and professional appearance at all times.

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4. Treating peers and colleagues with respect and dignity. 5. Taking personal responsibility for your education and its results

VII. Grading:

You will be graded against a standard and NOT on a curve with your current classmates. All attending evaluations are normalized to remove any tendency of the attending to grade easy or hard. All students are initially graded against the standards listed below for Honors, High Pass, Pass, Condition, and Fail. If a student’s grade is borderline, a “clerkship score” is given to the student and the entire student’s performance is reviewed in detail.

1. Pass. For a grade of PASS, the student is expected to meet the following criteria:

1. Have two adequate/passing ward evaluations (average scaled score 5 or greater).2. Pass the Practical Exam.3. Score above the 5th percentile on the shelf exam.4. Adequately complete and turn in all grade sheets on time (H&Ps, Worksheets, Presentations).5. Be an active participant in Clerkship School.6. Have a good record of Professionalism.7. Have no unexcused absences

2. High Pass. For a grade of HIGH PASS, the student is expected to meet the following criteria:

1. Have two excellent ward evaluations and ranked in the top 1/3 of students by attending.2. Score in the top 50% on the Practical exam.3. Score above the 50th percentile on the shelf exam.4. Thoroughly complete and turn in all grade sheets on time (H&Ps, Worksheets, Presentations)5. Be an active participant in Clerkship School.6. Have an outstanding record of Professionalism.

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7. Have no unexcused absences.

3. Honors. For a grade of HONORS, the student is expected to meet the following criteria:

1. Have two outstanding ward evaluations and ranked in the top 10% of students by attending.2. Score in the top 25% on the Practical exam.3. Score in the 80th national percentile or greater on the shelf exam.4. Thoroughly complete and turn in all grade sheets on time (H&Ps, Worksheets, Presentations)5. Be an active participant in Clerkship School6. Have an outstanding record of Professionalism7. Have no unexcused absences

5. Borderline Grade. For any students who are just below the criteria for a better grade, the clerkship committee will evaluate the students’ performance in detail. Benefit of the doubt may be given for students with exceptional performance on the wards. The shelf exam will never trump poor ward performance no matter how excellent the shelf score. Also, a poor professionalism grade automatically removes the student from consideration for the higher grade.

6. Condition Grade. If a student passes all aspects of the course, but fails the shelf exam he or she will receive a CONDITION GRADE and need to repeat the shelf exam. If the student fails the shelf exam again, he or she will need to repeat the entire clerkship before graduation from medical school.

7. Failure. If a student fails a ward evaluation, the clerkship committee will evaluate his or her clerkship performance. Unless there is substantial evidence to refute the ward evaluations, there are two possible outcomes. Depending on the degree of failure, the student may receive a CONDITION GRADE and need to repeat a month of wards to receive a passing grade. If the degree of failure is egregious or severe, the student will fail and need to repeat the entire clerkship.

***Failure of the practical exam will result in the student repeating the exam until he or she passes.

***Failure of the shelf exam requires the student to retake the exam and pass. If the student fails the shelf exam a second time, he or she will need to repeat the entire clerkship.

7. Breakdown – this is used to determine the overall composite grade. This will be considered by the clerkship committee for students who are borderline or do not meet the full criteria as described below for Honors, High Pass, and Pass.

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Ward Evaluations: 60.0%

H&Ps/Worksheets 5.0%

Practical Exam: 10.0%

Shelf Exam: 20.0%

Professionalism: 5.0%

***It should be noted that failures of professionalism may preclude any student for consideration of a higher grade. Also, failure to complete and turn in documents for the portfolio may also preclude any student from consideration for a higher grade.***

***All final grades will be determined by the clerkship committee***VII. Books

The Clerkship endorses the following as resources:

1. Alguire PC –ed. Internal Medicine Essentials for Students 3. United States: American College of Physicians and Sheridan Books, 2011.

2. MKSAP for Students 5 . United States: American College of Physicians, 2011.

3. Tulane Medicine Intern’s Handbook . - $15 in the residency office. Pick them up from Leigh-Ann or Phillip.

4. Sabatine M. Pocket Medicine. Lippincott, Williams, and Wilkins.5. USMLE World Step #2 Internal Medicine Qbank

There are plenty of other resources available. Please use caution when choosing a “high-yield” book to prepare for the shelf. These “high-yield” books are best used as a supplement to another book that is well-grounded in pathophysiology. It is not necessary to buy Harrison’s or Cecil’s for the clerkship, but these are both excellent reference books for the future. It is not recommended that you buy separate books for the subspecialty portions of the clerkship. If you need additional resources, most are available through the library.

VIII. Food and Bags

1. Sorry, food is not provided. Food can be bought at the Tulane Hospital cafeteria and the basement of University Hospital. On-call, it is commonplace for students to drive to pick-up food for the team. Students should be reimbursed for all food consumed by residents or interns.

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2. It is strongly recommended that you never leave valuable items in a bag lying anywhere in the hospital. Do not carry bags in and out of patient rooms. Carry what you need in your pockets.

IX. Dress Code

1. Men are expected to wear shirt, tie, slacks, and dress shoes to work everyday.

2. Women are expected to dress professionally (skirt or slacks are both acceptable) and wear closed-toed shoes (OSHA regulation).

3. Scrubs are not permitted unless you have spent the night in the hospital.

4. All students are expected to wear their white coat and ID.

5. Any student dressing provocatively or not adhering to the dress code while seeing Internal Medicine patients will lose some or all of the professionalism grade and may be sent home if necessary.

X. Hygiene

Despite the long hours you will spend at the hospital, you are expected to maintain excellent hygiene. This not only includes washing your hands (or using alcohol gel) after you see every patient, but normal everyday hygiene (shower, grooming, etc).

XI. Days Off

Students should average one day off per week. Students have a total of seven days off that should be taken over the duration of the clerkship. Days off cannot be taken when the team is on-call or post-call. Days off should be on weekends, unless there are extenuating circumstances. All students on a team may take the same day off, but this is ultimately left to the discretion of the attending. Any absences count against days off.

XII. Absences

Unexcused absences will result in failure of the Clerkship. The only person who can officially excuse students from clinical and academic duties is Dr. Kahn. The student is expected to notify the ward team, Leigh-Ann Sallis and Dr. Miller of any absences. Absences count against days off for the rotation. Any student who misses more than three days will be expected to make-up clinical time after the clerkship. Any days missed will count against total days off for the clerkship.

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Students who are excused in advance (i.e. wedding, scientific meeting, etc)for more than one day from the clerkship are required to submit a 1000 word essay on one of the following topics related to medicine:

1. The importance of professionalism2. The importance of patient advocacy3. The importance of being a team player

These essays are used to demonstrate student commitment to these ideals – professionalism, patient advocacy, and being a team player that may be called into question by extended absences. This ensures that there is documentation that all students who complete the clerkship adhere to these ideals. This must be completed on time to pass the clerkship.

Students who miss a call night are required to perform an additional student presentation for each night missed. Please see “Student Presentations on an IM Topic” on page 13 for more details. Because students will miss an opportunity to admit a new patient and perform an entire H&P, the “Student Presentation” will help fill a small part of the void from the educational opportunity missed. This must be completed on time to pass the clerkship.

If a student misses more than one day and a call night, he or she must submit both the essay and perform an additional student presentation.

If a student becomes ill, he or she is responsible for contacting his or her medical team and Dr. Miller as soon as possible. He or she will need to complete a CHIT form when well. If a student is ill for two or more days, he or she must provide a physician’s note or see or speak to Dr. Miller in person. Days taken for illnesses are subtracted from total number of days off. Students who fall ill are expected to adhere to the same make-up requirements (including missed calls) above as students with excused absences in advance. Extenuating circumstances may result in the forgiveness of any make-up work from absence caused by illness (or death in the family), but this will be at the discretion of the clerkship director.

XIII. Clerkship Checklist

These are the following things that must be completed and turned-in to pass the clerkship.

1. History and Physical #1 (Perfect Score)

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2. History and Physical #2 (Perfect Score)3. Student Presentation #1 grade sheet and one-page summary4. Student Presentation #2 grade sheet and one-page summary5. Completion of HPI Observation Form #16. Completion of HPI Observation Form #27. Completion of 2nd Paragraph and PMH Observation Form #18. Completion of 2nd Paragraph and PMH Observation Form #29. Completion of Physical Exam Observation Form #110. Completion of Physical Exam Observation Form #211. Completion of A&P Observation Form #112. Completion of A&P Observation Form #213. Patient Encounters entered in to E-value

XIV. A Few Potential Student Pitfalls

1. Waiting to begin reading. You need to read something every night. There is just too much to cover.

2. Withholding questions. Questions prompt discussion and learning. There are times when questions are not appropriate, but these moments will be obvious (i.e. during a code)

3. Not being around (on-call). If you stray too far away your resident may forget to call you or not have time to call you (i.e. code) and you risk missing something interesting or exciting.

4. Not taking initiative. You are part of the team now. If you see something that needs to be done (and you can do it), by all means offer to do it! The passive student will always receive a poor evaluation.

5. Being late. As it stands, you are the lowest on the pecking order. Tardiness will be heavily frowned upon. Not only is it unprofessional, but it will be seen as a sign of sloppiness, disorganization, and not caring about your patients (really).

6. Finally, expecting information and expectations to always be delivered to you. Neither will. Be active in seeking out information and expectations.

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