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Orientation to the Clerkship in Family Medicine 2015-2016 Department of Family and Social Medicine Albert Einstein College of Medicine
Orientation to the Clerkship
in Family Medicine 2015-2016
Department of Family and Social Medicine Albert Einstein College of Medicine
Who We Are
∗ Co-Directors, Medical Student Education Maria Teresa Santos, MD Mark Polisar, MD
∗ Assistant Director, Medical Student Education Lisa Lapman, MD
∗ Medical Education Specialist Zoon Naqvi, MBBS EdM MHPE
∗ Director,
Community Health Outreach Heather 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? Co
ntin
uous
&
Com
preh
ensi
ve Acute Care /
First Contact Pregnancy Knee pain Sore
throat Rash
Preventive Care
Weight Safe sex Shots
Chronic Disease Management
Sugar Heart
Blood pressure
Low mood
Wheezing
Primary Care Expertise
∗ Expertise is generalist practice
Overlapping Expertise
Pediatrics Obstetrics/ Gynecology
Primary Care Expertise
Pediatrics Obstetrics/ Gynecology Primary Care
Medical Education
Most other clerkship training
Medical Education
Family Medicine clerkship training
Most other clerkship training
Diversity in Practice Settings
Career in Family Medicine
∗ Largest specialty in the United States (70,000)
∗Average salary (2011) ∗ Starting: $138,000 ∗ Practicing 6 years: $199,850
Career in Family Medicine
∗ Largest specialty in the United States (70,000)
∗Average salary (2011) ∗ Starting: $138,000 ∗ Practicing 6 years: $199,850
∗ Loan repayment/forgiveness & scholarships ∗ AAMC Programs (83) ∗ National Health Service Corps
∗ 3 year residency program
Why Am I a Family Doctor?
Adapted from UCSF http://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. Lisa Lapman
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 Competencies ∗Healer ∗ 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 [email protected] 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 10 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 EXPERIENCE DIDACTIC SESSIONS
Family Medicine Clerkship
Practice Skills Develop Knowledge
Address Community-Based Prevention
Clinical Experience
COMMUNITY PROJECTS
CLINICAL EXPERIENCE DIDACTIC 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. Lapman 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. Lapman d. Dr. Santos e. Dr. Polisar
Buonora, Ms. Michele
[email protected] Dr. Joel Bumol Jamaica Hospital Medical
Speak to Dr Dovnarsky
Chiu, Ms. Elaine [email protected] Dr. Mark Polisar Williamsbridge FP (MMG)
Dr. Reichert, St. Barnabas 3/7, 2PM
^ Goldberger, Ms. Elizabeth
[email protected] 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
[email protected] Dr. Lisa Lapman Downtown Family Medicine
Dr. Reichert, St. Barnabas 3/7, 2PM
^ Kinstlinger, Mr. Noah
[email protected] 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 [email protected] Dr. Joel Bumol Mount Hope Family Practice
Dr. Reichert, St. Barnabas 3/7, 2PM
Witonsky, Mr. Jonathan
[email protected] Dr. Joel Bumol 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 team
THE 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 Feedback
Reviewing 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 Encounter Feedback 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 ∗ fmCASES ∗American
Family Physician
Independent Study
∗ eMED ∗ fmCASES ∗American
Family Physician
∗ Point of Care Superpages
Independent Study
∗ eMED ∗ fmCASES ∗American
Family Physician
∗ Point of Care Superpages
∗ Textbook
Team Question 4
What famous (probably copyright-protected) cartoon character can be found on the Point of Care Superpages?
a. Spiderman b. Batman c. Dora the Explorer d. Thomas the Tank Engine e. Curious George
Team Question 4
What famous (probably copyright-protected) cartoon character can be found on the Point of Care Superpages?
a. Spiderman b. Batman c. Dora the Explorer d. Thomas the Tank Engine e. Curious George
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 EXPERIENCE DIDACTIC SESSIONS
Family Medicine Clerkship
Project Objectives
∗ Demonstrate written and verbal communication skills with patients (individual and in groups), peers, community partners, and faculty.
∗ Implement and evaluate 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 15%
Weekly Check-In Minutes N/A
Self-Reflection (initial & final) N/A
CLERKSHIP 100%
Didactic Sessions
COMMUNITY PROJECTS
CLINICAL EXPERIENCE DIDACTIC SESSIONS
Family Medicine Clerkship
Didactic Sessions
∗ Independent Study (readings and modules)
∗ Seminars
∗ Team-Based Learning (TBL)
∗ fmCASES
∗ Objective Structured Clinical Encounter (OSCE)
Seminars
∗ Low Back Pain: Complementary / Alternative Medicine Approaches
∗ Lesbian, Gay, Bisexual, and Transgender Health
∗ Intimate Partner Violence
Team-Based Learning
∗ Prevention
∗Hypertension and Hyperlipidemia
∗Diabetes
∗ Students work individually and as a group to achieve a common educational goal
∗ Interprofessional 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) available in eMED
∗ PCORE module(s), the post-module feedback survey, and 5-question practice quiz
PCORE
PCORE Modules
TBL Phase 2: Readiness Assurance
In-class ∗ Individual Readiness Assurance Test (IRAT) ∗ 10 minutes: 5-item quiz on Scantron form ∗ Bring Banner ID and #2 pencil
∗ 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 ∗ Bring completed Case Analysis Tool Worksheet ∗ Helps prepare for analyzing 2 cases along w/ final exam
fmCASES
∗ Two stations on communication ∗ shared decision making ∗ palliative care
∗ Each station ∗ 10-minutes with simulated patient (trained actor) ∗ 5 minutes of feedback (including self-assessment)
∗ Required but not graded
Objective Structured Clinical Encounter (OSCE)
∗ Optional for 2015-2016 ∗ Offered 2 Thursdays per month 8 to 9am ∗ May be integrated into clinic schedule at your
site ∗ Can log in ∗ From site if open at 8am ∗ From home for sites that open later
∗ Prioritize starting patient care at your site on time ∗ Login information available on the 4-week
schedule in eMED: https://montefiore.webex.com (password: Fmgr3544)
Grand Rounds
Professionalism
COMMUNITY PROJECTS
CLINICAL EXPERIENCE DIDACTIC 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 EXPERIENCE DIDACTIC 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 55
55 = Honors 51 = High Pass 47 = Pass 43 = Low Pass
Community Project 20 Hand-off: 15 points Site Advisor: 5 points
Clerkship Exam 15
(Passing minimum: 65% correct or 1.5 SD below the mean,
whichever is lower; Failing: zero points)
Clinical Vignettes 10 5 points x 2 vignettes
TBL Combined IRAT/ GRAT N/A 65% average over 3 sessions or make-up written assignment
Palliative Care Assignment^ OCE Exercise^ OSCE Session^
N/A Points lost for incompletes
TOTAL POINTS 100
OVERALL GRADE CUT-OFF
Honors 91
High Pass 83
Pass 75
Low Pass 65
Fail N/A
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 ∗ Didactic sessions and fmCASES: 100% of questions ∗ 50 multiple choice questions (15%) ∗ Passing threshold: 65% or 1.5 SD below mean,
whichever is lower ∗ 2 fmCASE vignettes for analysis (10%) ∗ Exam results will be posted in eMED
∗ 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!
