CEEU-4011 - A/I in Intensive Community Medicine Clinical Immersion

CEEU-4011 - A/I in Intensive Community Medicine Clinical Immersion

Elective Title: A/I in Intensive Community Medicine Clinical Immersion
Course Number: CEEU-4011
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 3
Prerequisites: Successful completion of Year 2
Additional Requirements: C-form required to register, send form to Marta Rivera.
Responsible Faculty Director: N. Miles Farr, MD, MPH Periods Offered: 1-7, 9-13 excluding holiday period 8 
Coordinator: Marta Rivera Other Faculty: Nadia Ahmed, MD; Mary Suna Wilkerson, MD; Julian Quiceno, NP; and Martha Diaz, RN
Location to Report on First Day:
St. Vincent's Hope Clinic, 2817 Post Office, Galveston, TX 77573

To make a difference in our local community, while at the same time enhancing your clinical skills and improving your mastery of the art of medicine.

1. Practice and master placing lab, medication, and referral orders in the electronic medical record.
2. Obtain proficiency in agenda setting for outpatient visits and seeing patients in the outpatient setting efficiently, while obtaining key clinical information.
3. Give succinct, complete oral presentations that allow for efficient transfer of knowledge and excellent patient care.
4. Improve your efficiency in writing succinct, well-reasoned progress notes.
5. Practice giving well-reasoned assessments of patient common conditions and begin to practice independent medical decision making.
6. Demonstrate and apply a basic clinical knowledge of the diagnosis, treatment and management of common chronic illnesses and identify challenges to comprehensive care and treatment for uninsured individuals with these conditions.
7. Obtain knowledge of the important non-biological determinants of poor health and of the economic, psychological, social, and cultural factors that contribute to the development and/or continuation of maladies.
8. Learn from firsthand experience about the needs, structure, function, and resources of underserved communities in the greater Galveston area.

Description of course activities
The student will rotate through the community clinics including St. Vincent's Hope Clinics, mobile community clinics affiliated with St. Vincent's Hope Clinic, and FQHC Coastal Health and Wellness. You will be expected to see patients independently, present to faculty, and teach and mentor junior students. Students will participate in a minimum of 40 hours of clinical time each week. Students schedule will vary depending on the selected clinics each week as there are a multitude of opportunities each week. The times listed in weekly clinical schedule includes the range of options for all the clinics, students and faculty will meet to discuss the rotation and assign clinics accordingly.
Note: Clinic schedule below may not require you to be there the entire time, it will depend on the assigned clinics.

Type of students who would benefit from the course
Students interested in enhancing their clinical skills in preparation for residency and interested in working with an under-resourced population.

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday 7:45am 7:45pm
Tuesday 7:45am 7:45pm
Wednesday 7:45am 7:45pm
Thursday 7:45am 7:45pm
Friday 7:45am 7:45pm
Saturday 9:30am 3:30pm (clinic not required every week)

 Average number of patients seen per week: 30 (10 clinic sessions x 3 patients)
 Call Schedule: no

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
    Daily in clinic with designated preceptors.
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    Faculty Preceptors
  B. Frequency / Duration of Presentation(s)?
    Every clinic session
  C. Format - What guidelines are set for the student's presentation?
    Generally expected oral presentations skills taught in POM and clerkships
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    - H&Ps and progress notes on each patient they see as an acting intern, daily while on clinic days. - 1 reflection - based on specified criteria, assignment by end of the course
  B. Format - What guidelines are set for the student's written work?
    - Standard outpatient note expectations, templates to guide notes will be shared. - Reflection - based on specified criteria with detailed instructions, due by the end of the course.
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
    no references needed, but the assignment is: - Standard H&P and progress notes - Reflection - ~ 1 page single spaced or a representative project with approval of course director
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    - Student choice, guidance provided on topic options
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    - As outlined above, no additional activities

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    This elective will give the students act as an intern in an outpatient clinical environment including the above key year 4 epas listed above. They will give formative feedback from written "coaching" cards completed by supervisors and oral feedback.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
    - initial and follow-up clinical notes on Epic
- Oral Presentations of patients seen independently to their preceptor
- Work with interprofessional team members in multiple clinics each week
- Have the opportunity to participate in ongoing QI initiatives in clinic

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    - Increased responsibility to see prepare for and see patients independently prior to presenting to a preceptor
- Practice teaching and mentoring junior students as will be the expectation as an AI
- See answers to A / B above

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
    - office based procedures - joint injections (goal of 1 during rotation), ECG's (~ 3 to 5 per week), echocardiograms (at least 1 during rotation) pending needs in the clinic
- case report possible


An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    Student will work a full clinic schedule each week and be responsible for writing orders, writing patient notes, calling patients to follow-up on lab results and diagnostic studies, and ensuring proper follow-up. In addition, student will serve as a teacher and guide to junior medical students, as is an expected responsibility of an intern/acting intern working with medical students.

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    - Will have enhanced responsibility in the clinics as an acting intern, see above.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    - Written "coaching cards" required as part of participation. Faculty preceptors will discuss performance of student and discuss any concerns at midpoint and give the student an opportunity to improve performance.

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    - 2 core faculty and 1 NP that student will work with each week, they have sufficient exposure to faculty for the faculty to write a well-informed recommendation letter.