Format of the Clerkship

The two-month Clerkship in Internal Medicine is divided into two four-week units so that each student will rotate through two Medicine service ward assignments. These are at the University of Kansas Medical Center (KUMC) and the Kansas City Veterans Affairs Medical Center (KC VAMC).

While several of these services are oriented to sub-specialties, all admit general medicine patients and the emphasis, as far as Internal Medicine students are concerned, is general medicine. Students are expected to be at the hospital six days per week except for days officially designated as recess or holiday or unless the student has been specifically excused by the attending physician and has notified the student coordinator or director.

Many conferences are scheduled at the two hospitals. Attendance is mandatory at Faculty-Student Interaction Sessions, unless excused for good cause, by prior arrangement. Unexcused absences will be noted in your personal grade letter, copies of which are sent to the Dean of the Medical School and the Chairman of the Department. Conferences are carefully planned and scheduled to acquaint medical students and house staff with the current knowledge and understanding of medical problems.

Course Content

The Internal Medicine clerkship is organized to expose the student to curricular content through clinical and didactic activities as follows:

• Ward/Clerkship experience and direct patient care
• Faculty-student interactions
• Clinical Case conferences
• Online clinical Cases using SIMPLE
• Departmental seminars, didactics

Specific course topics/methods of delivery are detailed in Appendix B

Skills, competencies and knowledge assessment and verification

The following methods will be used to assess student progress and performance throughout the clerkship:

1. Formal write-up* (FWU)
2. Oral Presentation (OP)
3. Written examination (WE)
4. Observed performance (ObP)**

*Formal write-ups include the department database form, critical case summaries, and progress notes.

** Observed performance includes student demonstration of interview and examination skills, data gathering/interpretation, clinical reasoning, and extemporaneous discussion during teaching conference, and completion of online clinical cases

Attitude

The School of Medicine maintains that the cornerstone to sound clinical practice is an attitude of professionalism. In this regard, the Internal Medicine Clerkship has the following expectations:

1. Students will demonstrate a compassionate, empathetic and caring attitude toward his/her patients. (ObP)
2. Students will demonstrate full accountability in the performance of all ward duties and clerkship activities. (ObP)
3. Students will show an ability and willingness to function successfully as a member of the ward patient care team.(ObP)
4. Students will demonstrate the work ethic necessary for a successful physician, including reliability and availability. (ObP)
5. Students will show enthusiasm for learning and be active participants in their education. (ObP)
6. Students will show themselves to be teachable, soliciting and accepting feedback and responding to constructive criticism. (ObP)

THE PROBLEM ORIENTED MEDICAL RECORD (FWU)

The Department of Medicine is committed to the use of the Problem-Oriented approach to medical record keeping. This begins with the structured Data Base which will be completed for each new inpatient at KUMC and the VAMC by the Internal Medicine student, and corrected and certified by the appropriate housestaff and attending physician. Progress notes will be indexed by a Problem List as a part of this system of record keeping. The student's familiarity with and use of the EMR system is assumed. Students will be continuously evaluated on the quality and content of daily progress notes, including documentation of patient progress and changing characteristics.

EVALUATION AND FEEDBACK

During the entire two-month clerkship each student is continuously evaluated by faculty and house staff on the various wards and in clinics (ObP). A formative written examination (WE) will be administered midway through the clerkship. Results and feedback will be presented to students and content discussed. A comprehensive written examination will be given at the conclusion of the two-month clerkship (WE). Each student must pass the final written examination to pass the course.

The RIME construct for Evaluation and Feedback

The Internal Medicine clerkship has adopted the RIME (Reporter, Interpreter, Manager, Educator) format for description and evaluation of clinical progress of learners through the clerkship. The RIME vocabulary introduced by Pangaro1 provides a simple common descriptive framework that can be used to measure progress by both faculty and students. The Internal Medicine Clerkship has made slight modifications to this basic framework to suit our educational goals as follows:

Reporter
Early/incoming students are expected to have most of these basic skills, and should work to progress beyond this level. Students with skills at this level at the end of the clerkship would likely perform in the Unsatisfactory/Low Satisfactory range.

• Accurately gather data
• Clearly communicate clinical facts about patients
• Obtain history
• Perform a basic physical examination
• Demonstrate basic knowledge of what to look for on history and physical
• Show a sense of responsibility and reliability

Interpreter
Most students should be performing at this level by the middle of the clerkship (4th week), and are expected to progress to higher levels. By the 8th week, students with skills at this level are likely to perform in the satisfactory range.

• Prioritize problems
• Formulate differential diagnoses
• Formulate clinical plans
• Interpret basic tests on hospitalized patients
• Achieve consistency in bedside skills, communication and interpersonal relationships with patients
• Requires higher levels of:
  • Knowledge
  • Skill in selecting the clinical findings that supports possible diagnoses
  • Judgment in applying test results to specific patients
• Active participation in care: "Own the patient".

Manager
Students are expected to perform at this level at the end of the clerkship. This level of skill equates with the functional skill level that will be necessary for the student to succeed as an intern in any specialty. Students with skills at this level will likely obtain a high satisfactory/superior evaluation

• Additional knowledge and skill and application of evidence-based medicine
• Comprehensive differential diagnoses
• Detailed and focused Assessments and plans
• Evidence of confidence and judgment in patient care and management
• Tailor plans to circumstances and preferences of patients
• Higher level of interpersonal skills including skills needed to discuss care options and to educate patients
• Technical skills and manual skills: Proficiency in cardiovascular examination, EKG interpretation and other competencies

Educator
Students should strive to attain this level of skill and knowledge in preparation for higher-level clinical responsibilities. While most students may not achieve this level during their junior clerkship, students who function at this level will most likely obtain superior evaluations.

• Evidence of going beyond the basics: Research, study, literature review, in-depth reading
• Share new knowledge with clinical team through presentations/discussions on rounds
• Demonstrating high level of professionalism and communication through mature and capable interactions with patient and team
• Understanding of clinical care delivery systems, and challenges in hospital care delivery
• Skill and critical appraisal off the literature.

1. Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. Nov 1999;74(11):1203-1207.

Study/Text Information

You will be loaned:

• Internal Medicine Clerkship Guide - 2nd edition (D.S. Paauw, Mosby 2003)
• American College of Physicians MKSAP for students 5
• American College of Physicians Essentials for Clerkship Students 5

Other Resources:

• SIMPLE Cases: These are a required component of the curriculum and are available to all students.
• MKSAP for Students 5 Digital: You may purchase an online license to access this resource.
• Harrison's Online:  Highly recommended as an authoritative Internal Medicine Textbook. It is available for free through the library online resource portal.
• UpToDate: A good clinical reference source. Also available for free through the library online resource portal.
• Internal Medicine Web Site (includes Faculty/Resident Rotation Schedules, Call schedules, Conference schedules, etc.)
• KU School of Medicine Educational Objectives Web Site
• Bates videos