Checklist:  Click on Me for Course Requirements

FAMILY MEDICINE CLERKSHIP HANDBOOK

Clerkship in Family Medicine:

COURSE CURRICULUM

  Overview

 The purpose of the Family Medicine Clerkship is to enable second-year Duke Medical students and clinical year Physician Assistant students to understand the principles of Family Medicine and their application in community practice. It introduces the student to clinical problems commonly encountered by family physicians, as well as to the unique aspects of community practice. Students confront the diversity of community and family health care needs, occupational and environmental issues impacting health, and learn about some of the resources available to meet these needs.

 The competencies outlined on the following pages are achieved by the students primarily through clinical experience in a community practice. This is supplemented by directed readings, discussions with preceptors, and completion of required written reports.

Feedback should occur on a daily basis.  Students should ask for feedback on their performance.  Self assessment is also critical to the success of the rotation.   Preceptors are responsible for a final written evaluation of the students' performance, which determines 50% part the student's final grade. Students evaluate the rotation and teaching effectiveness of their preceptors; this evaluation data is routinely shared with the preceptors.

Departmental faculty reviews all evaluation data, and is available to assist students in their learning and preceptors in their teaching skills. Students' final grades are determined by an overall review of clinical performance, final examination, and written reports.

Family Medicine Clerkship Directory

Jody Crabtree

Jody is the coordinator for the Family Medicine Clerkship. She can assist you with placement issues and serve as a liaison to campus faculty.

919-681-3066

Fax: 919-668-1785

Joyce Copeland, MD

Dr. Copeland is the clerkship director for the Duke Family Medicine. Please contact Dr. Copeland if there are academic problems or concerns during the clinical rotation. Ms. Crabtree can assist you in contacting Dr. Copeland.

copel002@mc.duke.edu

 LEARNING STRATEGIES

1. Patient Care

1. See patients with common problems in the office setting. Obtain feedback from preceptor on accuracy and appropriateness of data gathered, interpretations made, and proposed plans.
2. Supplement clinical experience with readings on common problems.
3. Maintain your daily encounter log in myEvaluations.

2. Readings

3. Discussions with preceptor and staff

1. Discuss with preceptor and business office staff the local demand for primary care services, availability of secondary and tertiary care and referral patterns and protocols.
2. Discuss the family issues, occupational and environmental exposure issues, access to care, local resources for Medicare/Medicaid patients and medically indigent, changes in his/her clinical behavior to reflect local economy, resources, values, culture, and demands and rewards of primary care practice with preceptors.
3. Observe preceptor's lifestyle, including professional activities, educational activities, community services, etc.

4. Chronic Disease Management Case Report (START EARLY. PROCRASTINATION IS A SURE FIRE WAY TO MINIMIZE RESULTS.)

1. The Chronic Disease Management (CDM) Report: Required (click on link for details)

The chronic disease management report involves selection of a patient with a chronic disease and working through a case report that illustrates the components of CDM. This effort will include a look at the patient, the practice community, and the role of information technology in promoting evidence based disease management.

You will be introduced to the report at orientation and will receive a template for the case report.  You will also receive reading material and audiovisual media to assist in your understanding of the principles of chronic disease management.

You are encouraged to consider a home visit with the patient, especially if the office visit does not allow time to obtain the necessary family history.  This is NOT required.  A “windshield” tour of the patient’s neighborhood will be useful as well.  You will use the skills that you learn in the Community Health Orientation to approach this case report. You are encouraged to consider a home visit with the patient, especially if the office visit does not allow time to obtain the necessary family history.  This is NOT required. 

You will use the skills that you learn in the Community Health Orientation to approach this case.  The student is encouraged to visit at least one of the identified community resources.  Focus on the patient's self-management goal. 

 

5. SOAP notes

1. Prepare 2 SOAP notes per instructions in the section on documentation. 
2. NO Personal Health Information included. 
3. Be sure to have your name on the note.
4. Include a problem list and medication list.
5. Each note should focus on an individual problem.

6. Skills assessment

1. Complete the skills assessment table on day one for your own self assessment
2. Review the list with the preceptor midway through the rotation
3. Repeat the assessment at the end of the rotation.

7. Interim assessment

1. Schedule meeting with preceptor mid-rotation.
2. Review your progress
   1. Share your myEvaluations patient log
   2. Share your skills assessment review
3. Provide the preceptor with the interim assessment form for completion.
4. Submit the form at debriefing. (REQUIRED)

8. Required campus meetings

1. Students are required to attend a scheduled orientation session prior to departure for their rotation sites.
   1. This provides an overview of the course objectives, activities, and grading standards.
   2. The contrast between the primary care site and their tertiary care rotations is discussed, and suggestions on how to integrate into a busy primary care practice are reviewed.
   3. Departmental faculty review of problem oriented format and focused history/physical exam.
   4. Legal limitations on student behavior during the rotation are outlined, and suggestions for obtaining maximum benefit from the rotation are discussed. 
   5. Chronic disease management lecture
   6. Dermatology workshop
2. The required debriefing session is held upon the student's return from the community sites. Students compare and contrast their own experiences with those of students from other sites, and discuss their case. The Post-course quiz will be administered at the debriefing session in the Pickens classroom. The debriefing session begins at 8:00 am. 
3. The Chronic Disease Management Report, registries and essay should be submitted electronically 24 hours prior to debriefing.  Notify Ms. Crabtree  if you have any problems with submission such as Internet access.
4.  You will complete course evaluations online after debriefing.  Grades will NOT be submitted until confirmation of course evaluation survey and completion of the community health modules.

CFM 205: EVALUATION OF STUDENT PERFORMANCE

3. A written exam will be administered at the debriefing session. The exam will focus on the learning objectives outlined in the common problems goal.  This exam will count toward the final grade. Preparation for the exam should consist of extensive reading on common problems in conjunction with clinical exposure to common problems during the rotation. The exam comprises 15% of the grade.  (See Common Problems for objectives).  The information on the course CDs (Chronic illness, Patient Safety, Real World).

The course grade is determined by a composite of these data sources. Component grade values are converted to a 100 point scale and the report to the registrar is based on the outcome. Honors grades require a total of 93-100 points.

5 points will be deducted from the grade if any of the required material is submitted late...i.e. absolute deadline of noon on day of debriefing. 

Any component with any personal health information included will receive a 0 (zero) for that component.

ANY PAPER WITHOUT THE STUDENT'S NAME ON THE DOCUMENT WILL NOT BE GRADED AND THE POINTS WILL BE DEDUCTED FROM YOUR SCORE.

  CFM 205: STUDENT RESPONSIBILITIES

Establish a collegial relationship with the preceptor.

Students are asked to call the preceptor and introduce him/herself prior to the clerkship. We hope that the preceptorship will be a rewarding relationship for both the preceptor and the student. The preceptor should be able to answer most questions that arise during the rotation.

Complete the learning objectives of the course.
 
 

Integrate into the usual work pattern of the practice.

Provide a high level of patient care congruent with your level of training, and ask for the preceptor's supervision and consultation whenever necessary.

Select and complete the Chronic Disease Management Report and Registries

Call early regarding problems on the clerkship.

            Clerkship Coordinator

crabt003@mc.duke.edu

telephone # (919) 681-3066

Clerkship Director

(Joyce.copeland@duke.edu)

fax: (919)668-1785 (Notify Ms. Crabtree that you are sending a fax).

SUGGESTIONS FOR STUDENTS ON INTEGRATING INTO A COMMUNITY PRACTICE

PRECEPTOR RESPONSIBILITIES

1.  Notify your colleagues and staff of the student's arrival and role in the practice.
2.  Maintain a collegial relationship with the student.
3.  Establish a learning contract with the medical student. Review the course goals and objectives.
4.  Provide opportunities for supervised clinical experience.
5.  Inform patients that they are being seen by a supervised Duke medical student.
6.  Provide an orientation to the community and life outside the clinic.
7.  Supervise and evaluate student's progress.
8.  Provide the student with constructive feedback frequently.
9.  Perform a careful evaluation of clinical performance.

DEPARTMENTAL RESPONSIBILITIES

1. Communicate with students and preceptors about the program, and be available when questions or problems arise.
2. Administer the program, including matching students with preceptors and funding housing and limited travel for in-state sites.
3. Provide orientation and debriefing sessions for the student.
4.  Evaluate the student reports and provide a final grade that summarizes the student's performance.
5.  Assist preceptors in improving their teaching skills, including assistance in dealing with unusual student problems.
6.  Monitor the educational quality of the clerkship.
7. Assure that students are properly trained in the issues of patient confidentiality.  All students will receive HIPAA training prior to the clerkship.  They will also have necessary immunizations.

THE PROBLEM-ORIENTED MEDICAL RECORD

Your SOAP notes for grading need to include the acute problem or chief complaint, a chronic problem list and current medication list. 

The problem-oriented format is generally agreed upon as the optimal structure for medical records in primary care. This format separates information relevant to each medical problem, making it easier to locate and access appropriate information for follow-up or later care. The design is similar to the daily progress note in the inpatient setting....NOT the admission work up.

In the Problem-Oriented Medical Record, each problem addressed during a visit is documented with a separate SOAP note under a heading identifying the problem in question. Thus, a visit covering 2 problems would have a note with this structure:

Problem 1:

S

O

A

P

Problem 2:

S

O

A

P

It is acceptable for the objective section to be omitted, if no examination or relevant labs were done in this visit. Thus, a third problem could be noted:

Problem 3:

S

A

P

Occasionally, a problem being followed elsewhere or deferred to another visit may warrant a brief notation of subjective only, or subjective and plan.

Further details on this format are included in the guidelines on the following page.

Common errors/variations which do not meet this standard include:

Example:

S 1

S 2

O

A 1

A2

P 1

P 2

Example: (the commonly used format for inpatient notes)

S

O

A 1

P1

A2

P 2

A3

P 3

Guidelines for SOAP notes

Problem Heading: Every note should have a heading at the top indicating the problem, either in terms of the patient's complaint or in terms of the diagnosis. Encounters with multiple problems should have each problem written as a separate SOAP format.

 Subjective: The first problem in any encounter should begin with the patient's age and sex, followed by the chief complaint. The subjective section should include the history of the present illness, including pertinent positives and negatives. This may be followed by relevant past medical history, family history, social history, and/or current medications.

 Objective: The relevant aspects of physical examination should be described in standard format, i.e. the following order:

(1) General appearance

(2) HEENT

(3) Neck and back

(4) Lungs

(5) Cardiac

(6) Breast exam

(7) Abdominal exam

(8) Pelvic or genital/rectal exam

(9) Extremities

(10) Neurological exam

Only the relevant portions of exam should be described; the order should not vary. This should be followed by relevant laboratory or x-ray results from the current or previous encounters.

 Assessment: If the diagnosis is definite or likely, it should be clearly stated. If the diagnosis is uncertain, the primary symptom may be stated and the differential diagnosis described, including indications of the likelihood of various possibilities.  The assessment is NOT the plan.  The common and incorrect practice of A/P is unacceptable. You assessment should provider the reader with a clear picture of your thinking and justification for the plan.

 Plan: All instructions, medications, pending tests, and other discussions with the patient should be documented clearly. The medication data should include dosage, instructions, number of tablets/amount, and refills.  Document the instructions/warnings that you gave the patient as well.

The plan for follow-up, by telephone, writing, or a return encounter, should be indicated, along with instructions on what the patient is to do if the symptoms do not respond as expected. Any referrals should be indicated with the name of the physician the patient is to see, if that is available. The plan should also document patient education.

In some cases, the history and examination for several problems will be closely related, and difficult to separate into independent SOAP notes (e.g., diabetes and obesity, HTN and CAD). In those cases, it may be acceptable to write one subjective and objective section, with related assessments and plans. This should not be the norm, but may occur in occasional situations. If in doubt, the student should discuss with the preceptor prior to writing the chart note.

Self Assessment

Recognition of Skills and Learning Needs

Please take time to review skills evaluation before going to your site.  Identify the items that you feel comfortable addressing based on prior experience as well as those you feel are areas for improvement.

The form will help you determine your comfort with common skills needed in ambulatory care. You will be exposed to opportunities to advance your acumen in many of the competencies listed on the form.

Discuss the results of your review with the preceptor on the first day of your rotation. Use the results to develop a learning plan for the rotation. Focus on emphasizing the skills that you feel weak in. The preceptor will also have the opportunity to verify and acknowledge those areas in which you have more confidence. The exercise will also provide the preceptor with a database to assist in looking for ways to help you gain more skill.

Review the list frequently during your rotation so you can look for opportunities to add to your experience.

Finally, review and update the form at the end of the rotation to assess the competencies gained during the Family Medicine experience. Submit your Pre and Post skill forms at debriefing.

Complete your patient log in My Evaluations.

Please contract with your preceptor to review the status of your performance midway through the rotation. The form can serve as a guide for this process. The form for this purpose is located in the form folder. Provide the preceptor with a copy of your patient log to date so you can brainstorm ways to see more of the common problems if possible.

Each student will be asked to complete an assessment of their community preceptor. This information will be shared with the preceptor in an anonymous summary format. Departmental faculty will use the data to provide feedback on improving teaching methodology and for deciding who will get consulting faculty appointments. This form is due at debriefing. You may complete and save the form for printing or print the form yourself. The evaluation will be available at your survey site via BlueDocs.