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Learning Objectives of the Department of Medicine Regarding General Clinical Core Competencies

I. Diagnostic Decision-Making

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. key history and physical examination findings pertinent to the differential diagnosis.

2. information resources for determining diagnostic options for patients with common and uncommon medical problems.

3. key factors to consider when selecting from among diagnostic tests, including pretest probabilities, performance characteristics of tests (sensitivity, specificity, likelihood ratios), cost, risk, and patient preferences.

4. the relative cost of diagnostic tests.

5. how critical pathways or practice guidelines can be used to guide diagnostic test ordering.

6. the method of deductive reasoning.

B. Skills: Each student should be able to:

1. formulate a differential diagnosis based on the findings from the history and physical examination.

2. use probability-based thinking to identify the most likely diagnoses.

3. use the differential diagnosis to help guide diagnostic test ordering and sequence.

4. use pretest probabilities and scientific evidence about performance characteristics of tests (sensitivity, specificity, likelihood ratios) to determine post-test probabilities according to the predictive value paradigm.

5. participate in selecting the diagnostic studies with the greatest likelihood of providing useful results at a reasonable cost.

C. Attitudes: Each student should:

1. incorporate the patient’s perspective into diagnostic decision-making.

2. limit the chances of false positive/false negative results by demonstrating thoughtful test selection.

 

II. Case Presentation Skills

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. components of comprehensive and abbreviated case presentations (oral and written) and the settings appropriate for each.

B. Skills: Each student should be able to:

1. prepare legible, comprehensive, and focused new patient workups that include the following features as clinically appropriate:

    • present illness organized chronologically, without repetition, omission, or extraneous information.
    • a comprehensive physical examination with detail pertinent to the patient’s problem.
    • a succinct and, where appropriate, unified list of all problems identified in the history and physical examination.
    • a differential diagnosis for each problem (appropriate to level of training).
    • a diagnosis/treatment plan for each problem (appropriate to level of training).

2. orally present a new patient’s case in a logical manner, chronologically developing the present illness, summarizing the pertinent positive and negative findings as well as the differential diagnosis and plans for further testing and treatment.

3. orally present a follow-up patient’s case, in a focused, problem-based manner that includes pertinent new findings and diagnostic and treatment plans.

4. select the appropriate mode of presentation that is pertinent to the clinical situation.

C. Attitudes: Each student should:

1. demonstrate a commitment to improving case presentation skills by regularly seeking feedback on presentations.

2. Accurately and objectively record and present data.

III. History-Taking and Physical Examination

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. the significant attributes of a symptom, including location and radiation, intensity, quality, temporal sequence (onset, duration, frequency), alleviating factors, aggravating factors, setting, associated symptoms, functional impairment, and patient’s interpretation of symptom.

2. the four methods of physical examination (inspection, palpation, percussion, and auscultation), including where and when to use them, their purposes, and the findings they elicit.

3. the physiologic mechanisms that explain key findings in the history and physical exam.

4. the diagnostic value of history and physical exam information.

B. Skills: Each student should be able to:

1. use language appropriate for each patient.

2. use non-verbal techniques to facilitate communication and pursue relevant inquiry.

3. elicit the patient’s chief complaint as well as a complete list of the patient’s concerns.

4. obtain a patient’s history in a logical, organized, and thorough manner, covering the history of present illness; past medical history (including usual source of and access to health care, childhood and adult illnesses, injuries, surgical procedures, obstetrical history, psychiatric problems, hospitalizations, transfusions, medications, tobacco and alcohol use, and drug allergies); preventive health measures; social, family, and occupational history; and review of systems.

5. obtain, whenever necessary, supplemental historical information from other sources, such as significant others or previous physicians.

6. demonstrate proper hygienic practices whenever examining a patient.

7. position the patient and self properly for each part of the physical examination.

8. perform a physical examination for a patient in a logical, organized, respectful, and thorough manner, giving attention to the patient’s general appearance, vital signs, and pertinent body regions.

9. adapt the scope and focus of the history and physical exam appropriately to the medical situation and the time available.

C. Attitudes: Each student should:

1. recognize the essential contribution of a pertinent history and physical examination to the patient’s care by continuously working to improve these skills.

2. establish a habit of updating historical information and repeating important parts of the physical exam during follow-up visits.

demonstrate consideration for the patient’s feelings, limitations, and cultural and social background whenever taking a history and performing a physical exam.

IV. Communication And Relationships With Patients And Colleagues

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. how patients’ and physicians’ perceptions, preferences, and actions are affected by

cultural and psychosocial factors and how these factors affect the doctor-patient relationship.

2. the role and contribution of each team member to the care of the patient.

3. the role of psychosocial factors in team interactions.

4. the role of the physician as patient advocate.

B. Skills: Each student should be able to:

1. demonstrate appropriate listening skills, including verbal and non-verbal techniques (e.g., restating, probing, clarifying, silence, eye contact, posture, touch) to demonstrate empathy and help educate the patient.

2. demonstrate effective verbal skills including appropriate use of open- and closed-ended questions, repetition, facilitation, explanation, and interpretation.

3. determine the information that a patient has independently obtained about his/her problems.

4. identify patient’s emotional needs.

5. seek the patient’s point of view and concerns about his/her illness and the medical care he/she is receiving.

6. determine the extent to which a patient wants to be involved in making decisions about his/her care.

7. assess patient commitment and adherence to a treatment plan taking into account personal and economic circumstances.

8. work with a variety of patients, including multiproblem patients, angry patients, somatizing patients, and substance abuse patients.

9. work as an effective member of the patient care team, incorporating skills in interprofessional collaboration.

11. Give and receive constructive feedback.

C. Attitudes: Each student should:

1. work hard to develop effective doctor-patient communication skills.

2. take into consideration in each case the patient’s psychosocial status.

3. demonstrate respect for patients.

4. demonstrate actively involving the patient in his/her health care whenever possible.

5. demonstrate teamwork and respect toward all members of the health care team, as manifested by reliability, responsibility, honesty, helpfulness, selflessness, and initiative in working with the team.

6. respond pertinently to patient concerns.

7. attend to or advocate for the patient’s interests and needs in a manner appropriate to the student’s role.

V. Test Interpretation

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. the various components of a complete blood count, blood smear, electrolyte panel, general chemistry panel, electrocardiogram, urinalysis, pulmonary function tests, and body fluid cell counts and chemistries.

2. range of normal variation in the results of a complete blood count, blood smear, electrolyte panel, general chemistry panel, electrocardiogram, chest x-ray, urinalysis, pulmonary function tests, and body fluid cell counts and chemistries.

3. results of the above tests in terms of the related pathophysiology.

4. test sensitivity, test specificity, pre-test probability, and predictive value.

5. how errors in test interpretation can affect clinical outcomes and costs.

B. Skills: Each student should be able to:

1. interpret a blood smear, gram stain, electrocardiogram, chest X-ray, and urinalysis.

2. record the results of laboratory tests in an organized manner, using flow sheets when appropriate.

3. estimate post-test probability based on test results and state the clinical significance of these findings.

C. Attitudes: Each student should:

1. demonstrate estimating the implications of test results before ordering tests and after test results are available.

2. personally review X-ray films, blood smears, etc., to assess the accuracy and significance of the results.


VI. Therapeutic Decision-Making

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. information resources for determining medical and surgical treatment options for patients with common and uncommon medical problems.

2. key factors to consider in choosing among treatment options, including risk, cost, evidence about efficacy, and consistency with pathophysiologic reasoning.

3. how to use critical pathways and clinical practice guidelines to help guide therapeutic decision making.

4. factors that frequently alter the effects of medications, including drug interactions and compliance problems.

5. factors to consider in selecting a medication from within a class of medication.

6. factors to consider in monitoring a patient’s response to treatment, including potential adverse effects.

7. various ways that evidence about clinical effectiveness is presented to clinicians and the potential biases of using absolute or relative risk or number of patients needed to treat.

8. methods of monitoring therapy and how to communicate them in both written and oral form.

B. Skills: Each student should be able to:

1. formulate an initial therapeutic plan.

2. access and utilize, when appropriate, information resources to help develop an appropriate and timely therapeutic plan.

3. explain the extent to which the therapeutic plan is based on pathophysiologic reasoning and scientific evidence of effectiveness.

4. begin to estimate the probability that a therapeutic plan will produce the desired outcome.

5. write prescriptions accurately.

6. counsel patients about how to take their medications and what to expect when they take their medications, including beneficial outcomes and potential adverse effects.

7. monitor response to therapy.

C. Attitudes: Each student should:

1. incorporate the patient in therapeutic decision-making, explaining the risks and benefits of treatment.

2. respect patient’s informed choices, including the right to refuse treatment.

3. incorporate the elements of patient autonomy, treatment efficacy, quality of life, and societal demands into decision-making.

4. provide close follow-up of patients under care.

VII.Bioethics Of Care

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. basic elements of informed consent.

2. circumstances under which informed consent is necessary and unnecessary.

3. basic concepts of autonomy, treatment efficacy, quality of life, and societal demands.

4. potential conflicts between individual patient preferences and societal demands.

5. the role of the physician in making decisions about the use of expensive or controversial tests and treatments.

B. Skills: Each student should be able to:

1. participate in a discussion about advance directives with a patient.

2. participate in informed consent for a procedure.

3. participate in the care of a consent-requiring terminally ill patient.

4. participate in a preceptor’s discussion with a patient about a requested treatment that may not be considered appropriate (e.g., not cost-effective).

C. Attitudes: Each student should:

1. take into account the individual patient’s perspective and perceptions regarding health and illness.

2. demonstrate a commitment to caring for all patients, regardless of gender, race, socioeconomic status, intellect, sexual orientation, ability to pay, or cultural background.

3. recognize the importance of allowing terminally ill patients to die with comfort and dignity when that is consistent with the wishes of the patient and/or the patient’s family.

4. recognize the potential conflicts between patient expectations and medically appropriate care.

VIII. Self-Directed Learning

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. key sources for obtaining updated information on issues relevant to the medical management of adult patients.

2. a system for managing information from a variety of sources.

3. key questions to ask when critically appraising articles on diagnostic tests or therapies.

B. Skills: Each student should be able to:

1. perform a computerized literature search to find articles pertinent to a clinical question.

2. demonstrate critical review skills.

3. read critically about issues pertinent to their patients.

4. assess the limits of medical knowledge in relation to patient problems.

5. use information from consultants critically.

6. recognize when he or she needs additional information to care for the patient.

7. ask colleagues (students, residents, nurses, faculty) for help when needed.

8. make use of available instruments to assess one’s own knowledge base.

C. Attitudes: Each student should be able to:

1. demonstrate self-directed learning in every case.

2. acknowledge gaps in knowledge to both colleagues and patients and request help.


IX. PREVENTION

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. primary, secondary, and tertiary prevention.

2. criteria for determining whether or not a screening test should be incorporated into the periodic health assessment of adults.

3. general types of preventive health care issues that should be addressed on a routine basis in adult patients (i.e., cancer screening; prevention of infectious diseases, coronary artery disease, osteoporosis, and injuries; and identification of substance abuse).

4. vaccines that have been recommended for routine use in at least some adults (i.e., influenza, pneumococcal, measles, mumps, rubella, tetanus-diphtheria, hepatitis).

5. indications for endocarditis prophylaxis.

6. methods for counseling patients about risk-factor modification.

7. influence of age and clinical status on approach to prevention.

8. general categories of high-risk patients in whom routine preventative health care must be modified or enhanced (e.g., family history, travel to an underdeveloped area, etc.).

9. the major areas of controversy in screening.

B. Skills: Each student should be able to:

1. locate recently published recommendations regarding measures that should be incorporated into the periodic health assessment of adults.

2. identify patients at high risk for developing coronary artery disease and cancer by screening for major risk factors.

3. obtain a sexual history and counsel patients about safe-sex practices.

4. obtain and interpret a Pap smear report.

5. counsel a patient on smoking cessation.

6. perform a breast exam.

7. perform a digital rectal exam.

8. place and interpret a tuberculin skin test (PPD).

C. Attitudes: Each student should:

1. address preventive health care issues as a routine part of their assessment of patients.

2. encourage patients to share responsibility for disease prevention.

X. Coordination Of Care

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. the role of consultants and their limits in the care of a patient.

2. key personnel and programs in and out of the hospital that may be able to contribute to the ongoing care of an individual patient for whom the student has responsibility.

3. the role of the primary care physician in coordinating the comprehensive and longitudinal patient care plan, including communicating with the patient and family through telecommunications and evaluating patient well-being through home health and other care providers.

4. the role of the primary care physician in the coordination of care during key transitions (e.g., outpatient to inpatient, inpatient to hospice, etc.).

B. Skills: Each student should be able to:

1. discuss with the patient (and family as appropriate) ongoing health care needs, using appropriate language, avoiding jargon and medical terminology.

2. participate in requesting a consultation and identifying the specific question(s) to be addressed.

3. participate in the discussion of the consultant’s recommendations.

4. participate in developing a coordinated, ongoing care plan in the community.

5. obtain a social history that identifies potential limitations in the home setting which may require an alteration in the medical care plan to protect the patient’s welfare.

C. Attitudes: Each student should:

1. demonstrate teamwork and respect toward all members of the health care team.

2. demonstrate responsibility for patients’ overall welfare.

3. participate, whenever possible, in coordination of care and in provision of continuity

XI. Basic Procedures

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. key indications, contraindications, risks, and benefits of each of the following basic procedures:

    • venipuncture.
    • blood culture.
    • arterial blood gas.
    • electrocardiogram.
    • nasogastric tube.
    • urethral catheterization.
    • peripheral intravenous catheter insertion.
    • throat culture.
    • PAP smear.
    • digital rectal examination.
    • place and interpret a tuberculin skin test (PPD).

2. alternatives to a given procedure.

3. what the patient’s experience of the procedure will be.

B. Skills: Each student should be able to:

1. demonstrate obtaining informed consent, when necessary, for basic procedures, including the explanation of the purpose, possible complications, alternative approaches, and conditions necessary to make the procedure as comfortable, safe, and interpretable as possible.

2. demonstrate step-by-step performance of basic procedures with technical proficiency.

3. observe precautions and contraindications for the procedures used.

C. Attitudes: Each student should:

1. always participate in obtaining informed consent for basic procedures they perform or in which they participate.

2. explain what the patient’s experience is likely to be in understandable terms.

3. communicate risks and benefits to patients.

4. always make efforts to maximize patient comfort during a procedure.

XII. Geriatric Care

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. functional implications of aging organ systems.

2. special nutritional needs of the elderly.

3. key illnesses in the elderly, focusing on their often atypical presentation (e.g., urinary tract infection, pneumonia, tuberculosis, depression, thyroid disease, myocardial infarction, acute abdomen).

B. Skills: Each student should be able to:

1. take a history from a geriatric patient with special emphasis on physical and mental functioning.

2. perform a physical examination and functional assessment on an elderly patient, adapting it to possible conditions of frailty, immobility, hearing loss, memory loss, and other impairments.

3. perform a mental status examination to evaluate confusion and/or memory loss in an elderly patient.

4. identify patients at high risk for falling.

5. practice an interdisciplinary approach to management and rehabilitation of elderly patients.

C. Attitudes: Each student should:

1. always obtain historical information from significant others, whenever possible.

2. respect the increased risk for iatrogenic complications among elderly patients by always taking into account risks and monitoring closely for complications.

3. demonstrate respect to older patients by making efforts to preserve their dignity.

XIII. Community Health Care

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. how disease epidemiology in a community differs from that experienced in office or hospital practice.

2. how health care financing and organization affect individual patients, physicians, and the community.

3. how community and individual responses to health problems may be affected by both individual and community social characteristics.

4. local government, social service, or community organizations that provide links between the underserved members of the community and the medical care systems.

5. the barriers faced by his/her patients in the community setting.

B. Skills: Each student should be able to:

1. identify patients whose illnesses may put the community at risk.

2. identify the unique characteristics of a community that affect an individual’s health as well as that of the community.

3. consider how a patient’s community and cultural context may affect his or her approach to health care.

C. Attitudes: Each student should:

1. incorporate a population-based perspective in analyzing clinical problems.

2. use, in daily patient care, an understanding of the social characteristics of a particular community that affect patient attitudes toward health care.

XIV. Nutrition

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. key symptoms and signs that may indicate a nutritional problem.

2. nutritional problems that occur most commonly in adults.

3. common medical problems that can cause nutritional deficiencies.

4. contributions of dietary indiscretion to hyperlipidemia, diabetes, hypertension, etc.

B. Skills: Each student should be able to:

1. obtain a nutritional history for patients with obesity, hyperlipidemia, diabetes mellitus, hypertension, alcoholism, cancer, COPD, CHF, and GI diseases, giving attention to weight change, appetite, eating habits, digestive problems, dental problems, physical handicaps, psychiatric problems, socioeconomic factors, alcohol use, medications, and physical activity.

2. identify physical findings relevant to the nutritional assessment of patients including: truncal distribution, abdominal striae, cachexia, decubitus ulcers, temporal wasting, glossitis, peripheral neuropathy, peripheral edema, ascites, depression, and weakness.

3. order appropriate initial tests for evaluating a patient’s nutritional status.

C. Attitudes: Each student should:

1. assess the nutritional status of each patient.

2. consult a dietitian for patients with significant nutritional problems

XV. Advanced Procedures

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. key indications, contraindications, risks, and benefits of each of the following advanced procedures:

    • arthrocentesis.
    • central venous catheterization.
    • flexible sigmoidoscopy.
    • lumbar puncture.
    • thoracentesis.
    • paracentesis.
    • Swan Ganz catheterization.
    • bone marrow aspiration.
    • skin biopsy.

2. alternatives to a given procedure.

3. what the patient’s experience of the procedure will be.

B. Skills: Each student should be able to:

1. participate in obtaining informed consent for advanced procedures, including the explanation of the purpose, possible complications, alternative approaches, and conditions necessary to make the procedure as comfortable, safe, and interpretable as possible.

C. Attitudes: Each student should:

1. demonstrate responsibility for helping to provide informed consent.

2. demonstrate a commitment to explaining the patient’s experience in understandable terms.

3. communicate risks and benefits of procedures to patients regularly.

4. maximize patient comfort during a procedure.

XVI. Occupational Health Care

Specific Learning Objectives

A. Knowledge: Each student should be able to describe:

1. common environmental diseases likely to be encountered by an internist and identify the principal etiologic agents associated with them.

2. types of risks that may be encountered in a work site (i.e., ergonomic, inhalational, traumatic, chemical, heat, radiation, noise, and emotional stress); this should include the hospital and student-specific encounters.

3. information sources for determining the risk of specific environmental and occupational health hazards.

4. the purpose of the Occupational Safety and Health Act (OSHA) regulations.

B. Skills: Each student should be able to:

1. identify a patient whose health may have been affected by the living or work environment.

2. recognize common occupational health problems (e.g., carpal tunnel syndrome, asthma, asbestosis).

3. recognize when to refer a patient to a specialist in environmental and occupational medicine.

C. Attitudes: Each student should:

1. regularly assess the occupational risks of patients and elicit from patients any concerns that they may have about risks associated with their living or work environment.

XVII. Continuous Improvement in Systems of Medical Practice

A. Knowledge: Each student should be able to describe:

1. the principles of clinical quality improvement, including the notion of variation in practice as a quality issue and the concept of medical care as a process which can be studied and improved.

2. the analysis and improvement of systems to address common quality problems (treatment delays, medication errors, failure to give preventive care).

3. principles of medical record organization in both inpatient and ambulatory settings.

4. the need for a multidimensional approach to the assessment of quality, including the patient’s perspective of quality.

5. the relationship of quality and cost in health care.

B. Skills: Each student should be able to:

1. use hospital-based support systems to assist in making clinical decisions (e.g., antibiotic control program).

2. recognize systems flaws in the provision of care at the clerkship site (e.g., inability to arrange a post-discharge appointment within a needed time frame, delays in obtaining test results).

3. use patient education materials (e.g., pamphlets for patients started on warfarin) which help patients participate in their care.

4. use the medical records system efficiently and write legible notes.

5. work collaboratively with other health professionals in the delivery of care.

C. Attitudes: Each student should:

1. recognize the importance of systems especially interprofessional collaboration in delivering high quality patient care.

2. strive to improve the timeliness of their diagnostic and therapeutic decision making to improve quality of care, increase patient satisfaction, and reduce cost.

 

 
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