Department of Internal Medicine

College of Medicine

King Khalid University Hospital

King Saud University

 

            Course 441-Medicine Clerkship Manual

 

Revised

2009

 

Curriculum Proposal Form

 

*1 = clinical teaching
  2 = tutorials  

 

Curriculum revion date:  22/ 10/ 1429 (22/ 10 / 2009) 

 Revised by: 

Course Development committee :

Contents

 

Subject                                                                 page

 

Introduction...............................…………………………. 1

Clinical Training …………………………………………………...2-5

Important Dates To Remember ………………………………. 6

Executive Summary of Mark Distribution .................... 7

Assessment Exams ………………………………………………...8-13

Appendix – A (Sub – Intern Progress Note) ...……………14

Appendix – B (Tutorial Schedule) …………………………….15

Appendix – C (Long Case Feed Back Form) .………………16

Appendix – D (Skill to be acquired) ………………………...17-24

------------------------------------------------------------------------------- 

 

INTRODUCTION :

Patients seek medical attention for various reasons. These include:

1. Prevention of illness.
2. Relief of physical symptoms.
3. Control or preferably cure of an illness.
4. To find out about the prognosis of their illness.
5. Emotional comfort.

In order to address these needs, physicians need to be able to perform two different, but related, tasks:

1.      To arrive at a formulation of the patient’s problem(s), that includes a provisional or established diagnosis, and possibly a differential diagnosis. (Patients often have more than one problem at a time, and thus a “problem list” is needed.)
 

2.      To develop a management plan for their problem(s).

The goal of the medicine clerkship rotations (Course 441 Med.) is to assist the student in developing their competency in these tasks in the range of problems addressed by the discipline of internal medicine up to the level required for.. students to carry on  their practice as general practitioners or  continue their postgraduate training in any discipline, including internal medicine, family medicine and other specialty programs.

OBJECTIVES OF COURSE 441-MEDICINE :

At the end of the 441-Medicine course students are expected to:  

1)Master the skills of history taking and physical examination.

With the ability to Identify abnormal physical findings. 

2)Have asystematic and problem based approach to the diagnosis and management of common medical conditions. 

3)Be able to interpret the results of commonly use diagnostic tests. 

4)Be able to recognise patients with life threatening conditions &have asafe and organized approach to the diagnosis and management of common medical emergencies.  

5)Be able to communicate effectively ,both orally and in writing with patientsand other health care professionals 

6)Be able to pracise student centered learning in his/her free time using available resources.

These objectives will be realized by enforcing the ACTIVE INVOLVEMENT of the medical student in his/her own theoretical teaching and to be an ACTIVE MEMBER of the hospital team managing the patients rather than being merely an observer. Thus, it is not surprising that the bulk of the final assessment of the medical student will depend heavily on HOW ACTIVE the medical student was in the above mentioned tasks.

Appendix D- describes the skills to be acquired by medical students by the end of 441-Course in Medicine.

 

Description of the Course

The course will be for twelve (12) weeks,The student will be posted as sub-intern to a consultant of any sub-specialty ofMedicine, either in King Khalid University Hospital (K.K.U.H), Security ForcesHospital (S.F.H), and Riyadh Medical Complex (R.M.C), for six (6) weeks.

,In either end or at the beginning of the 7^th week, they will be changed to the otherspecialty of Medicine or other hospital as the case maybe.Each rotation is good for  six (6) weeks; therefore each student will be rotated twice.At the end of each rotation, the staff member will fill a form marking the student's        attendance, behavior, ability to take history, conduct physical examination, etc… This   marking will will be reflected in the CLINICAL ASSESSMENT MARKS.

1.  ROLE OF THE STUDENT ON THE WARD TEAM

Principle:  Learning at the clerkship level is best achieved by assuming, in a gradual manner, the roles played by real physicians. Therefore, the student should increasingly assume real and meaningful responsibility for patient care, and not act merely as an observer.

How the principle is realized:  The student becomes a full member of the medical team, which includes a consultant, a senior registrar/resident, one or more first-year residents, intern and other students.

The elements of being a full team member include the following tasks:

1.      Performing admission history and physical examination of minimum of 2-3 patients/week as assigned by the supervising consultant.

2.      Attempting to develop a differential and provisional diagnosis and to formulate a problem list.

3.      Documenting the details of the history, physical examination, impression and plan in the students Log Book (see below).

4.      Presenting (orally) a summary of their findings to the medical team during daily rounds, and at other occasions such as the unit round.

5.      Follow up of one's own patients on a regular basis with respect to the progress of their various problems.

6.      Documenting in the student;s Log Book  what is happening with the patient (i.e. writing progress notes regularly).

7.      Communicating with other people involved in the care of patients under their primary care e.g. (consultants, residents, consultation services, nurses and others).

8.      Gathering and reviewing relevant data, including laboratory and radiological data.

9.      Presenting at least one case history per week to the assigned consultant

• An example of writing a proper clinical progress note is provided in Appendix A.

 

 

2-ROLE OF THE STUDENT IN THE EMERGENCY ROOM

Principle: Taking on call duties in E/R is an essential component of learning in Internal medicine as this is where acutely ill patients are first assessed.

How the principle is realized:

1-On-call schedules will be arranged so that every medical student will be on call three to four times during the cycle, excluding weekends &final exam weeks.

2- Students are should join the on call medical registrar during their assessment of patients in E/R.

3-Students are expected to start their duties at 4PM and finish at 10PM.

4-Next morning students should attend their usual rounds &teaching sessions.

5-Every student is expected to take at least one full history&physical examination to be presented to his consultant next day.

6-The registrar on call will sign the student’s attendance sheet.

7- The evaluation of emergency room duties will be included in the clinical assessment section.

3. INTERACTIONS WITH THE “SENIORS”

Principles:

1.      The consultant is the individual best positioned to provide both "formative" feedbacks to students (advice about how to improve based on the student's performance so far) and a final judgment about the student's performance.

2.      The consultant is the most important internal medicine teacher the student will encounter. The attending serves as a professional role model, a source of clinically relevant knowledge, and a teacher of clinical skills.

3.      The interns, residents, and registrars will be the daily supervisors of the medical students.

How the principles are realized:                                                                                 the student will join the medical team in their daily rounds and present their own patients accordingly. The consultant will provide his/her own final assessment of the medical student taking in consideration also an overall feedback from the various team members. The medical student is encouraged to act as a SHADOW to his/her particular team and to be actively involved in its various activities.

4. TUTORIALS:

                    One tutorial per week on management of medical emergencies for the whole group will be given in the afternoon of every Wednesday. It can be given in Quiz format ,case scenario format or interactive discussion                                                       (See schedule below: Appendix B)

 

5. NEUROLOGY SESSIONS:

·                    The objective of these sessions is to increase exposure of students to patients suffering from conditions seen mainly in the sub-specialized division of neurology. 

·         All students will assemble every Tuesday, 10:00-12:00 noon in the Medical Ward 32-B Level 3 as arranged by Neurology Division.

·                    Each session will have one long case and one or two short cases. The students will be divided in two groups accordingly.

·                    32 – B Nurses at the station of Neurology Ward should notify the students about the case to be used for long case presentation. Notice should be given a day before the presentation no later than 12:00 noon.

·                    The assigned student will prepare the case one day earlier and present it with complete history and physical examination, Provisional diagnosis, differential diagnosis and plan for the investigation and management. He may then be asked by the teacher other things related to the case presented. Discussion is open then to the whole class and exchanged of questions is allowed. The student could be asked to demonstrate abnormal physical findings and interprets ECG, X-RAY or scans of the said patient. Between 60 minutes should be given for these long case discussions.

·                    The students assigned for short cases should be asked to do a physical exam of the patient. Student will be asked about the clinical findings after the examination; Physical examination should be timed and evaluated by the teacher. Each short case should take about 30 minutes.

6. INTERNAL MEDICINE MORNING ROUND:

Lecture Theatre C. Level 3. 07:45-08:30AM.   

7. BED SIDE TEACHING

The objective of bed side teaching is to help the student utilize his/her diagnostic skills to formulate a problem list for individual patients & be more familiar with how to investigate and manage  patient’s specific medical conditions.

 Each group of students will have one session/week with medical consultants of different subspecialties (excluding neurology) in which specific cases will be given to the students beforehand to take the history & physical examination & then the student will present the case to the consultant who will then discuss with students the patient’s problem list, how to investigate them, interpret the results of investigations and put forward a management plan & follow up. (See the attached schedule).

Recommended References

A.     Textbooks of Medicine

Any one of the following excellent books:

1. Clinical Medicine - A textbook for Medical students and doctors.  P. J. Kumar   and M. L. Clark “latest edition”.

2.  Textbook of Medicine - By Souhami andMoxham, latest edition

3. Davidson’s Principles and Principles of Medicines - C. R. Edward and                                      Ian, A.D. Bonchir, latest edition

B.      Physical Examination

 Any one of the following books :

1. A guide to physical examination and history taking by Barbara Bates,     latest edition.

2.  Macleod’s Clinical Examination by John Munro and C. Edwards

3. Clinical Examination - 2^nd Edition by Nicolas Talley and Simon O’Connor

 

 

Executive Summary of Mark Distribution:

 

Shown below a brief overview of the current mark distribution of different assessments in the course 441-Medicine: 

 1)   Ward Clinical assessment:        20% of the total mark

    a) 5% attendance.   b) 10% unit evaluation. c) 5% log book.

2)   Theoretical exam:                      30% of the total mark

3)    Mid-Term exam (Long Case): 20% of the total mark

4)    Final OSCE exam:                    30% of the total mark 

For each student, it is mandatory to obtain (18% out of 30%) in the final clinical (OSCE) to pass this course.

ATTENDANCE

 

Attendance is continuously monitored and kept to see whether students will meet the required percentage of attendance set by the University. As early as possible, any student noticed to have poor attendance would be given warning letters to call their attention and give them a chance to improve. As a rule, students should have attended at least 75% of each of the course clinical & theoretical activities   . Names of students who will have less than 75% attendance will be submitted to the Vice Dean – Academic Affairs Office and will not be included in the exam until the University gives their approval.

IMPORTANT DATE TO REMEMBER:

● CLASSES:

Start On	Saturday	11/10/1429	11/10/2008
End On	Wednesday	10/1/1430	7/1/2009

1.    FIRST ROTATION:

Start On	Saturday	11/10/1429	11/10/2008
End On	Wednesday	21/11/1429	19/11/2008

□ CONTINUOUS ASSESSMENT EXAM:

Start On	Saturday	1/12/1429	29/11/2008
End On	Tuesday	4/12/1429	2/12/2008

2.     SECOND ROTATION:

Start On	Saturday	24/11/1429	22/11/2008
End On	Wednesday	10/1/1430	7/1/2009

□ FINAL EXAMINATION:

Start On	Saturday	6/1/1430	3/1/2009
End On	Wednesday	10/1/1430	7/1/2009

   

 

3.         Assessment Exams 

-                     Theory Exam

This is a clinically-oriented theoretical assessment that involves Single-Best MCQ’s through patient case scenarios.  

-                     Clinical Exam

-         It consists of one long case for the mid-term exam and OSCE at the end of the course.

·       LONG CASE

The mid-term clinical exam will consist of one long case.  The goal here is to introduce the medical student to the clinical exam format mid-way in his/her training period so mistakes could be learned from and avoided in the future exams.  Each student has the right to repeat the exam if a clear evidence was submitted indicating an unfair exam (e.g. non-compliant patient). A one-page “long-case feedback” form will be filled immediately by the examiners that will be copied and then given to the student in order to improve his/her performance for the next exam. 

 

An example of how this form looks like is shown in Appendix C.

·       OSCE: (Objective Structured Clinical Examination)

-                     This part will include both of the short clinical cases in addition to the oral part in the old system:

-                     Rational: this will result in a more objective and standard exam by exposing the same students to the same examiners asking the same questions and have the ideal answers and mark distribution, with more efficient & effective use of time and staff.

-                     It includes 10 stations, and each station lasts for 7 minutes, so the total time for 1 OSCE is 70 minutes.

-                     The stations are divided into the following:

a - Data Interpretation Stations

b- Focused Clinical Stations.

 c -Rest Stations.

·                    10-11 students will undertake the OSCE at one time,  followed by a 10-minute break, 

       then another 10-11 students will undertake the OSCE.  

·                      Each student will be provided with 10 stickers that contain his/her name and university number that he/she will handle to the examiners to avoid wasting time in getting this information during the start of each station. 

 

·