Orientation to the Clerkship

in Family Medicine2016-2017

Department of Family and Social Medicine

Albert Einstein College of Medicine

Who We Are

DirectorMedical Student EducationMaria Teresa Santos, MD

Associate DirectorConair Guilliames, MD

Assistant DirectorOladimeji Oki, MD

Medical Education SpecialistZoon Naqvi, MBBS EdM MHPE

Director, Community Health OutreachHeather Archer-Dyer, MPH, CHES

Administrative Assistant

Adriana Nieto

Orientation: Part One

Family Medicine

In Context

Meet the Smiths

Sam

Dad

Grandma

Mom

Tanya

The Smiths’ Hopes

Grandma: See Tanya graduate from high school

Mom: Save money for kids’ college

Dad: Save money for retirement

Tanya: Make state championship in basketball

Sam: Learn how to use the toilet

The Smiths Hope for Health

Grandma: Live out retirement at home

Mom: One place to get care for her and her family

Dad: Find a doctor available after work

Tanya: Be able to see a doctor at school

Sam: Avoid getting more shots

The Smiths Engage the Health Care System

Everyone was on Dad’s insurance

Dad lost job during recession

Family went on Medicaid

Dad found new job – higher premiums / copays, fewer benefits

Grandma sicker due to lapsed care/ new insurance

Why Is Health So Expensive?

We Spend More

Source: http://www.healthsystemtracker.org/chart-collection/

We Spend Differently

Primary Care

Private Offices /

Community Health Centers

Secondary Care

Outpatient Surgery /

Office-based Specialists

Tertiary

Care

Inpatient

Hospitals

Tertiary

Care

Inpatient

Hospitals

Secondary Care

Outpatient Surgery /

Office-based Specialists

Primary Care

Private Offices /

Community Health Centers

Source: Schoen et al, Health Aff 2005; W5: 509-25.

US health care financing Health care financing

in Canada, Australia, and the UK

We Have Access Issues

Source: http://www.healthsystemtracker.org/chart-collection/

Runaway Prices

Source: Rosenthal E, Paying Till It Hurts, NY Times (nyti.ms/1qUUxXK)

Unnecessary or Harmful Care

As much as 30 percent of care delivered is duplicative or unnecessary, with no benefit, or even harm to people’s health

Choosing Wisely promotes conversations between clinicians & patients, to help patients choose care:

Supported by evidence

Not duplicative of other tests or procedures already received

Free from harm

Truly necessary

Source: ABIM Foundation (choosingwisely.org)

Less Health than We’d Expect

Source: WHO (DALE = Disability Adjusted Life Expectancy)

Primary Care Can Help

Health is better in areas with more primary care physicians.

People who receive care from primary care physicians are healthier.

The characteristics of primary care are associated with better health.

The supply of primary care physicians is associated with lower total costs of health services.

Access to primary care provides greater equity in health.

Barbara Starfield, Leiyu Shi, and James Mackino in 2005

What Is Primary Care?

What Is Primary Care?

Patient-oriented (vs. disease / organ)

Relationship-centered

What Is Primary Care?

Outpatient focus

Coordinated

Family Medicine = Primary Care…

For all ages

With a focus on care of patients, families, and communities in the context of their lives

What Is Primary Care?C

on

tin

uo

us

&C

om

pre

he

nsi

ve

Acute Care / First Contact

Pregnancy Knee pain Sore throat

Rash

Preventive Care

Weight Safe sex Shots

Chronic Disease Management

SugarHeart

Blood pressure

Low mood

Wheezing

Primary Care Expertise

Expertise is generalist practice

Overlapping Expertise

Pediatrics Obstetrics/

Gynecology

Primary Care Expertise

Pediatrics Obstetrics/

GynecologyPrimary Care

Medical Education

Most other clerkship training

Medical Education

Family Medicineclerkship training

Most other clerkship training

Diversity in Practice Settings

Career in Family Medicine

Largest specialty in the United States (70,000)

Salary (2016) Median: $188, 000 Usual Range: $165K to $215K 10% earn above $240,ooo

Career in Family Medicine

Largest specialty in the United States (70,000)

Salary (2016) Median: $188, 000 Usual Range: $165K to $215K 10% earn above $240,ooo

Loan repayment/forgiveness & scholarships AAMC Programs (83) National Health Service Corps

3 year residency program

Why Am I a Family Doctor?

Adapted from UCSFhttp://youtu.be/9uVhU0C3P1M

Advanced Training

Life Cycle

Adolescent Medicine

Reproductive Health

Geriatric Medicine

Academic

Primary Care Research

Faculty Development

Rural

General Surgery

Endoscopy

Niche

HIV Medicine

Sports Medicine

Palliative Care

Complementary Medicine

Community Health

Urgent Care

Hospitalist

Practice Improvement Principles

Patient-Centered Medical Home

Practice Improvement Examples

Open Access Scheduling

Phone, e-mail visits

Sharing MD visit with other health professionals

Patient registries

Intensive individual education

Group visits

Portable electronic health record

Patient decision aids

Collaborative mental health

Language translation

Patient navigation

Is Good Health Care Enough for Good Health?

The Smiths in their Community

The Smiths in their Society

Socio-Ecologic Framework

Macrosocial & environmental conditions & policies

Living & working conditions

Social, family, & community networks

Individual behaviors

Individual genetics/physiology

Over the life span

Working beyond the Clinic Walls

A New Model of Care for the Smiths

Health center in the neighborhood for whole family

Care management nurse & health educator (Grandma)

Evening hours (Dad)

Online chat overnight (Sam’s Mom)

Satellite school clinic (Tanya)

Health care network with community service plan, including links to public health department

Promoting healthy food options

Economic development programs

Education: fellows, residents, and medical students

Addressing community health as trainees

Future workforce

Family Medicine & Your Education

Approach to assessing and managing a clinical problem may be different in the ambulatory Family Medicine and community settings than in the hospital setting

The power and appropriateness of tests, procedures, and interventions is different in the clinic and the community than the tertiary hospital

Family Medicine & Your Education

Excellence in integrated patient care

The “biopsychosocial model of medicine”

Individual, family, community, public health

Appreciation for value of continuity of care

Comfort with breadth of medicine

Comfort with ambiguity

Mastering complexity

Stay Engaged

National: fmignet.aafp.org

Local FSMIG:

Dr. LadiOki(ooki@montefiore.org)

Orientation: Part Two

Nuts and Bolts

of the Clerkship

Interprofessional Teams

Health of patients depends on well-functioning teams

Most health teams bridge professions

Clerkship structured around teams

Care team in clinic

Community project team

Team-based learning didactic sessions

Get seated in teams:

http://emed.einstein.yu.edu/view/course/Medical/226

Clerkship Objectives

Einstein CompetenciesHealer

Scientist

Advocate

Educator

Colleague

Role Model

Life-long Learner

Objectives

Methods

Assessment

Where to Find Everything

A

B

C

D

1

2

3

4

5

6

7

E

F

How to Keep Track of Everything

How to Get Where You’re Going

All car service transportation through Vital

Booking via mobile website:

Register: https://transportation.einstein.yu.edu

Log in: AD/yuad user name and password

Confirm in Profile Page your cell phone / text preferences

Email nina.franchi@einstein.yu.edu your rotation / dates

Trouble making a reservation? Call Security: 718-430-2180

Transportation covered between Einstein, clinical sites, community project sites, ECHO, and palliative care sites for official activities

Carpooling required

Last resort: Contact Ms. Adriana Nieto (718-430-2900)

Team Question 1

There are 11 clerkship objectives. How many objectives contain either the word “family” or “families?”

a.1

b.2

c. 3

d.4

e.5

Team Question 1

There are 11 clerkship objectives. How many objectives contain either the word “family” or “families?”

a.1

b.2

c. 3

d.4

e.5

Clerkship Format

COMMUNITY PROJECTS

CLINICAL EXPERIENCEDIDACTIC SESSIONS

Family

Medicine

Clerkship

Practice SkillsDevelop Knowledge

Address Community-Based Prevention

Clinical Experience

COMMUNITY PROJECTS

CLINICAL EXPERIENCEDIDACTIC SESSIONS

Family

Medicine

Clerkship

Clinical Components

Orientation to Site

Patient Care

Midway Feedback

Observed Clinical Encounter

ECHO Sessions*

Patient Logs

Palliative Care Experience

*for students available on Saturdays

Orientation to Site

First or second day at continuity clinic

Site director or designee

Use orientation checklist as guide

Who? What? When? Where? How?

Objectives & Evaluation

Team Question 2

One student has forgotten who was assigned as their OCE preceptor. Check eMED and identify the preceptor scheduled to observe students at Jamaica Hospital Medical Center.

a. Dr. Dovnarsky

b. Dr. Bumol

c. Dr. Oki

d. Dr. Santos

e. Dr. Polisar

Team Question 2

One student has forgotten who was assigned as their OCE preceptor. Check eMED and identify the preceptor scheduled to observe students at Jamaica Hospital Medical Center.

a.Dr. Dovnarsky

b. Dr. Bumol

c. Dr. Oki

d.Dr. Santos

e. Dr. Polisar

Buonora, Ms.

Michele

michele.buonora@med.einstein.yu.edu Dr. Oladimeji Oki Jamaica Hospital

Medical

Speak to Dr Dovnarsky

Chiu, Ms. Elaine elaine.chiu@med.einstein.yu.edu Dr. Mark Polisar Williamsbridge FP

(MMG)

Dr. Reichert, St.

Barnabas

3/7, 2PM

^ Goldberger, Ms.

Elizabeth

elizabeth.goldberger@med.einstein.yu.edu Dr. Meg

Rosenberg

Family Health Center

(assigned Fri 2/26 &

3/4 AM in place of

ECHO)

Dr. Pinto, Weiler

2/29, 2PM

Khan, Mr.

Mohammad

mohammad.khan@med.einstein.yu.edu Dr. Oladimeji Oki Downtown Family

Medicine

Dr. Reichert, St.

Barnabas

3/7, 2PM

^ Kinstlinger, Mr.

Noah

noah.kinstlinger@med.einstein.yu.edu Dr. Maria Santos Castle Hill FP (MMG)

(sessions in place

of ECHO TBA)

Dr. Dovnarsky,

Jamaica Hosp, 2/29 at

1PM (see Ms Herrera

1st – see info below)

Kurochkin, Mr. Philip philip.kurochkin@med.einstein.yu.edu Dr. Conair

Guilliames

Mount Hope Family

Practice

Dr. Reichert, St.

Barnabas

3/7, 2PM

Witonsky, Mr.

Jonathan

jonathan.witonsky@med.einstein.yu.edu Dr. Oladimeji Oki Jamaica Hospital

Medical

Speak to Dr Dovnarsky

Clinical Sites

Residency Practices

Community Health Centers

Private Practices

ECHO free clinic

Clinical Visit Types

Health Maintenance

Acute Complaint

Chronic Problem Follow-up

Psychosocial

Behavior Change

Clinical Tasks

Perform comprehensive H&P in 60 minutes

Perform focused H&P in 30 minutes

Manage chronic med conditions

Develop prevention plans

Identify psychosocial, cultural issues

Refer when appropriate to specialists

Work as part of a health care teamTHE PATIENT IS ON THE TEAM

Clinical Expectations

Independent evaluation of patients

Daily case presentations and chart notes

Password and log ins for EMR

Prompt attendance and involvement in all scheduled clinics and local site didactics

Energy and enthusiasm matter

Professionalism

Professionalism

Exhibit empathy, respect, and non-judgmental behavior towards patients, families, team members, residents, faculty, and each other

Display dependability and responsibility

Report any mistreatment by faculty or residents to your clerkship directors

Mistreatment

Web-based complaint form available- OSA web page- “for students” web page

Ombuds Panel- 2 faculty members; 2 fourth-year students- investigate all complaints

Assistant Dean at each site involved in addressing issue with alleged perpetrator

Assistant Dean reports back to Ombuds Panel who- updates the student- reports to OSA, OME, Dr. Burns

https://www.einstein.yu.edu/education/student-affairs/mistreatment-reporting-form/

Working with Patients

Provide patient with proper gowns and minimize exposure

Wash your hands before and after each visit

Ask patients for permission to do a physical exam

Get a chaperone for breast, gynecologic, and GU exams

Report any needle sticks to student health immediately! Needlestick Hotline: 917-729-0438

Clinical Feedback

Clinical Performance Assessment Purpose Encourage brief daily feedback

Provide info for midway feedback & final evaluation

Student: Choose 2 items to be evaluated each session / day

Complete all items at least once during rotation

Preceptor(s): Evaluate 1 item

Circle description

Comments

Verbal feedback

Clinical Feedback

Midway FeedbackReviewing strengths and areas for improvement

Print midway logs

Complete self-assessment prior to session

Review and co-sign both with site director

Return form and log to Adriana Nieto

Form must be returned no later than 1 week before the clerkship exam. Students who have not submitted a midway feedback form will not be able to sit for the exam.

Observed Clinical EncounterFeedback on interview and physical exam skills

Not graded

See schedules folder for faculty observer

Team Question 3

How many specific conditions are students required to log during the Family Medicine clerkship?

a.15

b.20

c. 25

d.30

e.35

Team Question 3

How many specific conditions are students required to log during the Family Medicine clerkship?

a.15

b.20

c. 25

d.30

e.35

Patient Logs Minimum of 40 patient encounters

Student average: 60-80 patients per rotation

Keep logging past minimum Always enter your primary clinic site as the

site of the log entry (NOT Einstein)

Patient Logs Minimum of 30 conditions

Patient Logs Minimum of

12 performed and 2 observed procedures

Patient Logs Review at midway feedback Seek remaining conditions and

procedures Use independent study

materials for conditions / procedures not completed by end of 3rd week enter alternate experiences

in log

Patient Logs

All logs must be completed by 11:59pm, 2 schooldays before the clerkship exam. Students with incomplete logs will not be able to sit for the exam. Logs completed after the last day of the clerkship will preclude a grade of honors.

Independent Study

eMED

Independent Study

eMED fmCASES

Independent Study

eMED fmCASESAmerican

Family Physician

Independent Study

eMED fmCASESAmerican

Family Physician

Point of Care Superpages

Independent Study

eMED fmCASESAmerican

Family Physician

Point of Care Superpages

Textbook

Palliative Care Experience

Reading / form in eMED

Seminar: Introduction to Palliative Care

Patient Interview and Debriefing Assignment at Palliative Care Clinical Sites

Community Projects

COMMUNITY PROJECTS

CLINICAL EXPERIENCEDIDACTIC SESSIONS

Family

Medicine

Clerkship

Project Objectives

Demonstrate written and verbal communication skills with patients (individual and in groups), peers, community partners, and faculty.

Implement evidence-based community-oriented health interventions.

Identify and recommend available community assets and resources to improve the health of individuals, families, and communities.

Discuss the role of socioeconomic, environmental, cultural, and other population-level determinants on health status.

Demonstrate team skills in learning and service contexts.

Project Components

Orientation History of the Bronx

Site Advisor

Workshops

Project Work Implementation & Evaluation

Weekly Check-Ins w/ Site Advisor

Midway Check-In w/ Community Health Outreach Director

Project Hand-off

Community Tour

More information to come

Project Evaluation

ASSESSMENT PERCENTAGE

Site Advisor Assessment 5%

Project Hand-Off 10%

Weekly Check-In Minutes N/A

Self-Reflection (initial & final) N/A

CLERKSHIP 100%

Didactic Sessions

COMMUNITY PROJECTS

CLINICAL EXPERIENCEDIDACTIC SESSIONS

Family

Medicine

Clerkship

Didactic Sessions

Independent Study(readings and modules)

Seminars

Team-Based Learning (TBL)

fmCASES

Seminars

Integrative Medicine

Lesbian, Gay, Bisexual, and Transgender Health

Intimate Partner Violence

Team-Based Learning

Prevention

Hypertension andHyperlipidemia

Diabetes

Students work individually and as a group to achieve a common educational goal

Inter-professional work with Columbia NP students

TBL Phases

Phase 1: Preparation

Phase 2: Readiness Assurance

Phase 3: Application of Concepts

TBL Phase 1: Preparation

Link to Primary Care Online Resources and Education (PCORE): http://edblogs.columbia.edu/pcore/

PCORE module(s)

PCORE

PCORE Modules

TBL Phase 2: Readiness Assurance

In-class Individual Readiness Assurance Test (IRAT) 10 minutes: 5-item quiz on Qualtrics

Group Readiness Assurance Test (GRAT) 10 minutes: same quiz on scratch cards

Teamwork is rewarded Grading Passing = minimum 65% combined score on IRAT / GRAT over

3 sessions (or else written make-up assignment) Helps prep for final exam

Instructor Feedback 15 minutes

Clarification and connection to clinical practice

TBL Phase 3: Application of Concepts

In-class hour 2

Apply core knowledge to conflicting, controversial, or emerging aspects of clinical, community, and public health issues

Not graded

Nationally shared resource for family medicine Case-based online modules work through diagnostic and management issues build knowledge and clinical reasoning skills

During clerkship, review 10 cases independently Multiple choice questions on exam from cases

3 Tuesday mornings, cases analyzed as a group Helps prepare for analyzing 2 cases along w/ final exam Case analysis worksheet - optional

fmCASES

Optional for 2016-2017 Offered 2 Thursdays per month 8 to 9am May be integrated into clinic schedule at your

site Can log in to Montefiore’s Zoom Webex From site if open at 8am From home for sites that open later

Prioritize starting patient care at your site on time

Login information is made available via email the day before the grand rounds session

Grand Rounds

Professionalism

COMMUNITY PROJECTS

CLINICAL EXPERIENCEDIDACTIC SESSIONS

Family

Medicine

Clerkship

General Expectations

Attendance and punctuality

Active independent study of materials related to learning experiences

Expected absence requests prior / unexpected absence notifications ASAP (see Policies and Procedures)

Communication

Read and respond to all Einstein email communication in a timely fashion

Report any broken links in eMED to Adriana Nieto and a Clerkship Director

Report any schedule conflicts immediately

Clerkship announcements are posted in eMED every Sunday

Evaluation

COMMUNITY PROJECTS

CLINICAL EXPERIENCEDIDACTIC SESSIONS

Family

Medicine

Clerkship

Overall Evaluation

LCME requirements: midway feedback / patient logs / clerkship evaluation Grades may be lowered due to: missed sessions^ / professionalism issues / late logs

COMPONENT POINTS NOTES

Site Director's Grade 50

50 = Honors47 = High Pass43 = Pass38 = Low Pass

Community Project 15Hand-off: 10 points

Site Advisor: 5 points

Clerkship Exam 15

(Passing minimum: 65% corrector 1.5 SD below the mean,

whichever is lower;Failing: zero points)

Clinical Vignettes 10 5 points x 2 vignettes

OSCEs 10

TBL Combined IRAT/ GRAT N/A65% average over 3 sessions

or make-up written assignment

Palliative Care Assignment^OCE Exercise^

N/A Points lost for incompletes

TOTAL POINTS 100

OVERALL GRADE

CUT-OFF

Honors 90

High Pass 83

Pass 75

Low Pass 65

Fail N/A

Overall Evaluation

No Quota for Honors

Strict Cut-offs – an 89.9 total equates to High Pass

Must perform well in all components

Clerkship Exam / Clinical Vignettes

Exam on computer using ExamSoft

• Will receive mock exam by email mid-rotation

• Download & verify functioning on your computer / tablet

2 hours

50 multiple choice questions (15%)

• Passing: 65% or 1.5 SD below mean, whichever is lower

• All questions are from didactics, TBL modules, fmCASES

2 fmCASE vignettes for analysis (10%)

• Cases are graded blindly

Exam results will be posted in eMED

Twelve stations

Each station is 7 minutes long

6 stations with standardized patient (SP) Focus is on communication/interpersonal skills

6 stations with “paper” cases Focus is on clinical knowledge/reasoning

Open-book

Lowest performing case from each station type will be dropped

OSCEs account for 10% of overall grade

Objective Structured Clinical Encounter (OSCEs)

Office for Educational Resources (OER): clinical overall, clinical & didactic teaching

Family Medicine SurveyMonkey: non-clinical aspects

Reminder: student feedback aggregated every 6 months, released only after grades filed –honest feedback drives improvements

Student Evaluation of the Clerkship

Have Fun!