MEDU-4097 - Acting Internship in Ambulatory Internal Medicine

MEDU-4097 - Acting Internship in Ambulatory Internal Medicine

Elective Title: Acting Internship in Ambulatory Internal Medicine
Course Number: MEDU-4097
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 2
Prerequisites: Successful completion of Year 2
Additional Requirements: Successful Completion of an IM Clerkship.
Responsible Faculty Director: Bernard Karnath, MD Periods Offered: 1-10, 12-13 including holiday period 8 
Coordinator: Victoria Garcia Other Faculty:
Location to Report on First Day:
Suite 107 Harborside Clinic

Develop independent thought process in evaluation, diagnosis and management of Internal Medicine patients in the Ambulatory Setting. To prepare the student to function as a house officer in clinic.

1. Student will improve and refine the ability to conduct an interview and perform a physical examination in an ambulatory setting.
2. For each patient encounter, the student will compile a relevant problem list and formulate differential diagnosis.
3. For each encounter, the student will develop a thoughtful and thorough assessment, and prepare plans for the management of the patient in clinic.
4. Students will refine skills of the oral presentation of the new patient, and follow up patients, to the ambulatory faculty.
5. Students will practice and improve the interpersonal skills needed to address the social and psychological needs of the patient and the family.
6. Students will develop skills in creation and execution of an appropriate management plan for common ambulatory medical problems.
7. Students will develop appropriate use of the medical literature as it relates to specific patient problems.
8. Students will become comfortable with an increased level of responsibility in the management of patients in clinic.
9. Students will coordinate follow up care and understand continuity of care.

Description of course activities
Each student will complete 4 weeks of ambulatory internal medicine training.

Students will rotate through Suite 105 and 107 at the UTMB Internal Medicine Harborside clinic. Activities are built around the AAMC Core Entrustable Professional Activities for Entering Residency as follows:
EPA 1: Gather a history and perform a physical examination
1. Obtain a complete and accurate history in an organized fashion and perform focused versus comprehensive physical examinations depending on the reason for clinic visit.
2. Demonstrate clinical reasoning in gathering focused information relevant to a patients care
EPA 2: Prioritize a differential diagnosis following a clinical encounter
1. Synthesize essential information from the previous records, history, physical exam, and initial diagnostic evaluations.
2. Develop the Chief Complaint and Integrate information to update differential diagnosis.
EPA 3: Recommend and interpret common diagnostic and screening tests
1. Recommend diagnostic evaluation for a patient with an acute or chronic common disorder or as part of routine health maintenance.
2. Interpret the results of basic diagnostic studies (both lab and imaging); know common lab values.
EPA 4: Enter and discuss orders and prescriptions
1. Enter prescription orders (new and refills) and discuss indications and risks with patients.
2. Enter orders for diagnostic studies and referrals and justify the need.
EPA 5: Document a clinical encounter in the patient record
1. Students will develop an understanding of the requirements and regulations regarding documentation in the medical record.
2. Students will accurately document the reasoning supporting the decision making in the clinical encounter.
EPA 6: Provide an oral presentation of a clinical encounter
1. Present information that has been personally gathered during the clinical encounter, acknowledging any areas of uncertainty.
2. Provide an accurate, concise, and well-organized oral presentation and adjust the oral presentation to meet the needs of the receiver of the information.
EPA 7: Form clinical questions and retrieve evidence to advance patient care
1. Develop a well-formed, focused, pertinent clinical question based on clinical scenarios or real-time patient care.
2. Demonstrate use of scientific reasoning in acquisition of knowledge and application to patient care. Students will present directly to faculty.
EPA 8: Give or receive a patient handover to transition care responsibility
1. Participate Hospital follow up care and document transitions of care and items for follow up.
2. Identify potential gaps in care from hospital to clinic and learn to use the Transitions of Care format for Hospital follow clinic notes.
EPA 9: Collaborate as a member of an inter-professional team
1. Identify team members roles in clinic and the responsibilities associated with each clinic member. Students may work with the clinic staff to obtain vital signs, POCT testing, and give immunizations and other injections.
2. Communicate with respect and appreciation to each team member and include them in relevant information exchange.
EPA 10: Recognize a patient requiring urgent care and initiate evaluation and management
1. Recognize normal vital signs and variations that might be expected based on
2. Recognize severity of a patients illness and indications for escalating care (e.g. chest pain, shortness of breath).
EPA 11: Obtain informed consent for tests and/or procedures
1. Understand and explain the, indications, risks, contraindications, benefits, alternatives, and potential complications of the procedure.
2. Documents the discussion and the informed consent in the EMR.
EPA 12: Perform general procedures of a physician
1. Participate in Venipuncture, Joint Injections, Immunizations, POCT labs (e.g. HgbA1c, INR, UA, etc.).
2. Understand and explain to the patient the risks, contraindications, benefits, alternatives, and complications of the treatment plan.
EPA 13: Identify system failures and contribute to a culture of safety and improvement
1. Understand the clinic system and vulnerabilities (e.g. lost to follow up care, continuity of care).
2. Speak up in the face of a potential errors or near misses during presentations.
3. Recognize severity of a patients illness and indications for escalating care (e.g. chest pain, shortness of breath).

Type of students who would benefit from the course
Any student who plans on entering internal medicine residency who wishes to have experience and training in an on-call setting with patients with acute or chronic disease.

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday 8:00 - 12:00pm 1:00pm - 5:00pm
Tuesday 8:00 - 12:00pm 1:00pm - 5:00pm
Wednesday 8:00 - 12:00pm 1:00pm - 5:00pm
Thursday 8:00 - 12:00pm 1:00pm - 5:00pm
Friday 8:00 - 12:00pm 1:00pm - 5:00pm

 Average number of patients seen per week: 30
 Call Schedule: N/A, must work 5 days per week (8:00am - 5:00pm)

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?
  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?
    Internal Medicine Faculty & Residents
  B. Frequency / Duration of Presentation(s)?
    6-8 times per day (after seeing patient)
  C. Format - What guidelines are set for the student's presentation?
    Students will be expected to present historical and physical examination data as it relates to their patients.
  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)?
    Students will write 6 clinic notes per day
  B. Format - What guidelines are set for the student's written work?
    Outpatient Clinic Note format is used in the Electronic Medical Records.
  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?
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    Relate to cases
  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)?
    Students are graded solely on their clinical performance.

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.
    Students should meet with clinic faculty at the end of each week for formative feedback. Feedback will include suggestions on how to improve verbal presentation skills, documentation in the electronic medical record (clinic notes), ability to enter orders and knowledge gaps in patient management.

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.
    Full participation in ambulatory patient care activities including histories and physical examinations, clinic note writing, and order entry. See EPAs listed above under Description of Course Activities.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    Full participation in ambulatory patient care activities including histories and physical examinations, clinic note writing, and order entry. See EPA's listed above under Description of Course Activities.

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)?
    Students will fully participate in the care of the ambulatory patient. Students will write a full clinic note on each patient seen and enter orders. Students are expected to see 3 patients per half day of clinic, which is the same requirement as PGY-1 interns. Students will have full access to Epic with the ability to document the clinical encounter and enter orders (e.g. prescription refills, diagnostic studies, referrals, laboratory studies, etc.).

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?
    The Ambulatory Acting Internship rotation will allow the student the opportunity to fully participate in outpatient care. Written requirements are only related to direct patient care (e.g., clinic notes in the electronic medical record).

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    Students should meet with clinic faculty weekly. The Faculty will evaluate the students ability to present patients, document in the electronic medical record, and provide an appropriate assessment and plan for each patient. Students will have the opportunity to improve their skills based on their weekly and mid-point feedback.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    Students are likely to work with 4 to 5 faculty over the course of the rotation. Students will work in the Firm system here at UTMB in the General Internal Medicine Clinic (i.e. Powell, Daniels, and Remmers).

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.
    Rotations are 4 weeks in duration. Students will work Monday through Friday in an Ambulatory setting with faculty supervision. Students will mostly work with faculty in their clinics but may also work with residents with faculty supervision. Faculty will provide feedback on Oral Presentations and Clinic Notes whether working directly with faculty or residents.