Appendix I:What you need in Internal Medicine
Appendix 2:Logbook
Appendix 3:Suggested learning meodules & core lecture series
Appendix 4:Admission note

Overview

The Internal Medicine Clerkship is one of the fundamental Clinical Experiences for medical students. In this Clerkship, students are expected to begin developing many of the basic competencies of doctoring. The 4th-year Junior Clerkship is designed to compliment the experiences in the 6th-year Senior Clerkship and in the Family Medicine Clerkship.

Those problems and medical conditions in Internal Medicine which will be emphasised are those that every Physician should be able to manage, regardless of their chosen specialty. We will provide you with Clinical and Didactic Experiences that should stimulate learning. This Curriculum- detailed below- specifies and prioritises Course Objectives in terms of the Basic Generalist Competencies, the Specific Learning Objectives (knowledge, skills and attitudes) pertinent to these Competencies and includes the Clinical Experiences and Evaluation Methods.

The ability to learn independently is an essential trait for every Physician to have and is very important for your success in this Clerkship. You will have opportunities to evaluate and take care of patients, discuss cases with your resident and attending Physician, present cases to both teachers and student colleagues at Case Presentations and participate in Tutorials addressing Common Clinical Problems. Each of these experiences should stimulate you to ask questions and to seek answers using the medical literature where appropriate. The effort which students are prepared to put into their degree will largely determine how successful the educational experiences of the Clerkships in Medicine will be for you and your colleagues.

You will spend 10 weeks on Medicine in Year 4 and 7 weeks in Year 6. The clinical site consists of a Consultant Physician, a Senior Resident (who is a second or third-year Post-Graduate Trainee), one or two Interns and a variable number of Medical Students.

While on the Clinical Teaching Site, you will be on-call with the team in the Emergency Room on average every fourth night. Students generally continue to look after all the patients that they have admitted and participate in all aspects of Patient Care under the supervision of the Consultant Physician and Senior Resident.
4th Year students look after up to 3 patients at a time and have a maximum of 4 patients. 6th Year students look after up to 4 patients at a time and have a maximum of 5 patients.

Goals & Objectives
Introduction To The Medicine Clerkship

Patients seek medical attention for various reasons. These include:

• For the prevention of illness.
• For the relief of physical symptoms.
• For the control or preferably cure of an illness.
• To find out about the prognosis of their illness.
• For 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 an Established Diagnosis, and possibly a Differential Diagnosis (Patients often have more than one problem at a time, and thus a “Problem List” may be needed).
2. To develop and implement a Management Plan for their problem(s).

The Goal of the Medicine Clerkship Rotations is to assist the student in developing their competency in these tasks in the range of problems addressed by the discipline of Internal Medicine, namely the Medical (non-surgical) Illnesses of adults. The level of competency which is needed to be achieved is that which is required for the student to carry on into Postgraduate Training in any discipline, including Internal Medicine, Family Medicine and other Specialty Training Programmes.
During the fourth-Year Clerkship, students are expected to achieve a basic degree of competence in Diagnosis, and to develop familiarity with Management, focusing on problems requiring in-patient care and illnesses encountered in the Ambulatory domain.
In the sixth-Year Clerkship, Diagnostic Skills should be further enhanced, competence in Management deepened, and the range of problems and illnesses dealt with broadened.

Guidelines For The Medicine Clerkship:

In order to achieve these Goals, we have developed guidelines for you and for your teachers: “objectives” that govern the rotation and how they are realised.

An “objective” means something a student should be able to do at the end of a period of instruction. These refer to demonstrable outcomes of education. Being able to perform these Objectives then enables the student to meet the Specified Goals.

Objectives Of The Internal Medicine Clerkship
Medical Expert/ Skilled Clinical Decision Maker

At the conclusion of the Clerkship in Internal Medicine, the medical student will be able to:

1. Demonstrate knowledge of the Scientific and Humanistic Foundations of Medicine, as learned during the Pre-Clerkship and expanded on during the Clerkship, in order to more rationally diagnose and manage the various factors contributing to a patient’s illness.
2. Demonstrate a thorough knowledge of Internal Medicine. This has three dimensions:

Relevant aspects of Common and Life-Threatening Illnesses (listed in Appendix 1) affecting adults in terms of the:

• Definition.
• Epidemiology.
• Etiology.
• Biological.
• Psychological.
• Social.
• Economic, Legal, Ethical and Cultural.
• Pathogenesis and Pathophysiology.
• Clinical Features.
• Complications.
• Investigations Required to Confirm a Diagnosis.
• Principles of Prevention.
• Principles of Management.
• Medical.
• Surgical.
• Involvement of Allied Health Professionals.
• Nutritional.
• Prognosis.

An approach to the Diagnosis of the Major Presenting Problems Encountered in Internal Medicine (these are listed in Appendix 1.)
In order to do this, the student needs to be able to:

• List, in an organised fashion, the major causes of each of these Problems.
• List the most Important or Life-Threatening Causes of each Problem.
• Explain how the Data that may be obtained from the History and Physical Examination will affect the likelihood of these Diagnostic Possibilities for each Problem.
• Understand the appropriate use and interpretation of Diagnostic Tests (see below).

The Properties of Medical Therapies, in terms of their indications, contraindications, mechanisms of action, side- effects and monitoring.
The major Medications and other Therapies for students to be familiar with are listed in  Appendix 1.

The depth of knowledge to be achieved is quite well represented by the amount of detail found in the references listed in the textbook list.

At the Conclusion of the Clerkship in Internal Medicine, the Medical Student will be able to:

Demonstrate Clinical Skills

Students should be able to obtain and document both a Complete and a Focused Medical History, as the situation requires. The History will be thorough and organised and supplemented as needed by information from other sources (family members, other health care institutions, other physicians, etc.).
Students should be able to perform and document both a Complete and a Focused Physical Examination, as the situation requires. In order to do this, students must be able to demonstrate:

• An understanding of the Physiologic Casis of Clinical Findings.
• A Logical, Comprehensive, Organised Approach to the Physical Examination that is adaptable to specific circumstances.
• The proper Techniques of Physical Examination.
• The appropriate attention to Patient Comfort, Hygiene and Privacy.
• An understanding of the significance of, and the ability to detect the presence of, the most important Physical Examination Abnormalities pertinent to Internal Medicine, listed in Appendix 1.

Students should be able to interpret Commonly-Employed Diagnostic Tests. The Major Tests that are pertinent to Internal Medicine are listed in Appendix 3. In order to use these effectively, students are required to know their indications, contraindications, risks and- in general terms- their test characteristics (sensitivity and specificity).

Students should be able to integrate the above History, Physical Findings and Diagnostic Test Results into a meaningful Diagnostic Formulation. This requires that the student can:

• Generate a Problem List.
• Generate a Differential Diagnosis for each of the problems, and suggest a Tentative or Provisional Diagnosis.

Students should be able to demonstrate Therapeutic and Management Skills. In order to do this, the student needs to be able to:

• Suggest Appropriate Additional Investigations for each Problem.
• Propose a Management Strategy for each of the problems based on knowledge of efficacy, risk and cost. By the end of the 4th-year, students should be able to write Admitting Orders for each of the Common Diagnoses encountered in Internal Medicine, listed in Appendix 1.

Students should be able to demonstrate the Technical Skill necessary to perform many of the Common Procedures used in Internal Medicine, as well as show that they understand the indications, risks and benefits of these Procedures. These Procedures are summarised in Appendix 1.

Many of these Procedures have the following properties in common:
The need for cleaning the skin; anesthesia; the insertion of needles and obtaining specimens; paying attention to Infection Control.

Make use of Evidence-Based Medicine (EBM) so that they can better Diagnose and Manage Patient Problems. The major concepts of EBM pertinent to Internal Medicine are listed in Appendix 1. 

Communicator/Doctor-Patient Relationship:

At the Conclusion of the Clerkship in Internal Medicine, the Medical Student will be able to:

1. Communicate effectively with patients, their families and the community through verbal, written and other non-verbal means of communication.
2. Establish professional relationships with patients, their families (when appropriate) and the community that are characterised by understanding, trust, respect, empathy and confidentiality.
3. Deliver information to the patient and their family (as appropriate) in a humane manner, and in such a way that it is easily understood, encourages discussion and promotes the patient’s participation in decision-making.
4. Gather information, negotiate a common agenda, and develop and interpret a Treatment Plan, whilst considering the influence of factors such as the patient’s age, gender, ethnicity, cultural and spiritual values, socio-economic background, medical conditions and communication challenges.
5. Present a Case Summary orally in a clear, logical and focused manner, including:
   
   • Pertinent Positive and Negative Findings from the History, Physical Examination and Investigations.
   • A Problem-Oriented Summary and a Differential Diagnosis.
   • A Plan for Further Investigation and Management.
6. Document, in writing, all aspects of the Procedure, including: the results of the History, Physical Examination and Diagnostic Tests, the Problem List and Differential Diagnoses, and the Management Plan of the Patient Encounter in the Patient Chart. This should be done in a clear, organised and legible manner to a standard demanded by the fact that this is a Legal Document. For hospitalised patients, this includes:

• The Admission and Discharge Notes.
• Daily Progress Notes that consist of: a Problem List, Relevant Changes in Symptoms and Physical Findings, the Results of Investigations, Plans for Future Work-Up, Therapeutic Interventions Administered and Responses to Therapy.
• Admission and Subsequent Orders that are unambiguous and legible.

Collaborator

At the Conclusion of the Clerkship in Internal Medicine, the medical student will be able to:

• Describe the roles and expertise of all the members of the Interdisciplinary Team that are involved in the Care of Patients with an Internal Medicine Problem.
• Develop a Care Plan for a patient that he/she has assessed, including: Investigation, Treatment and Continuing Care in collaboration with the members of the Interdisciplinary Team.
• Participate in Interdisciplinary Team Discussions, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing an appropriate level of expertise to Patient Care.

Manager

During the Clerkship in Internal Medicine, the medical student will deepen his/her understanding of the appropriate use of Health Care Resources in the context of Internal Medicine.

Health Advocate/Community Resources

At the Conclusion of the Clerkship in Internal Medicine, the medical student will be able to:

1. Accept appropriate responsibility for the Health of Patients assigned to their care.
2. Recognise the important determinants of health and the principles of Disease Prevention pertinent to Internal Medicine.
3. Act as an advocate on behalf of patients assigned to their care when interacting with other members of the Health Care Team.

Scholar

At the Conclusion of the Clerkship in Internal Medicine, the medical student will be able to:

• Demonstrate the ability to engage in Self-Directed Learning. This involves identifying Personal Learning Objectives then finding and using a variety of resources to address Learning Needs and using Self-Reflection to assist their own Learning.
• Assist in teaching others and facilitating learning where appropriate.

Professional

Throughout the Clerkship in Internal Medicine, the medical student will:
Behave in an altruistic manner, as he/she:

• Demonstrates sensitivity to patients’ needs.
• Takes time and effort to explain information to patients.
• Takes time and effort to comfort sick patient
• Listens sympathetically to patients’ concerns.
• Puts patients’ interests before his/her own.
• Shows respect for patients’ confidentiality.

Demonstrate reliability and a strong sense of responsibility as he/she:

• Completes assigned tasks timely and fully.
• Fulfills the obligations undertaken.
• Takes on an appropriate share of the team work.
• Fulfills call duties.
• Reports accurately and fully on Patient Care Activities.
• Always ensures the transfer of responsibility for Patient Care.
• Informs the supervisor/team when mistakes occur.
• Informs the supervisor/team when faced with a conflict of interest.

Demonstrate a commitment to excellence via self-improvement and adaptability as he/she:

• Accepts constructive feedback.
• Recognises their own limitations and seeks appropriate help.
• Incorporates feedback to make changes in their behaviour.
• Adapts well to changing circumstances.
• Reads up on patient cases.
• Attends rounds, seminars and other learning events.

Demonstrate respect for others, as in the course of relationships with  students, the Faculty and staff, he/she:

• Establishes a rapport with team members.
• Maintains appropriate boundaries in work and learning situations.
• Relates well to fellow students in a learning environment.
• Relates well to the Faculty in a learning environment.
• Relates well to other Health Care Professionals in a learning environment.

Demonstrates honour and integrity by upholding student and professional codes of conduct as he/she:

• Refers themselves accurately with respect to qualifications.
• Uses appropriate language in discussion with patients and colleagues.
• Resolves conflicts in a manner that respects the dignity of those involved.
• Behaves honestly.
• Respects diversity of race, gender, religion, sexual orientation, age, disability, intelligence and socio-economic status.
• Maintains appropriate boundaries with patients.
• Dresses in an appropriate professional manner (context specific).

Strategies For Meeting The Learning Objectives
Initial Orders

Write Initial Orders on patients where possible.
Have the Supervising Resident review all Student-Initiated Orders.
Have the Supervising Resident counter-sign all Student-Initiated Orders.

Patient Follow-up

• Follow the results of Patient Workups where possible.
• Order Diagnostic Procedures as appropriate.
• Discuss Diagnostic Options with the Faculty.
• Research the Case and supplement with appropriate readings.
• In the event of the death of a patient, attend and participate in the Autopsy, if possible.

Problem List

• Formulate an up-to-date Problem List or its equivalent for each patient and post it in the front of the chart.
• Use library resources to research the Problem List.
• Read professional journals thoughtfully and be able to identify the characteristics of effective medical articles.
• Patient Interaction.
• Develop sensitivity to and an understanding of the Ethical Dimensions of Patient Care.
• Develop an understanding of the Psycho-social, Educational, Economic and Religious Backgrounds of patients that underlie their diverse Belief Systems; demonstrate this understanding in the Approach to the Management of individual patients.

Presentations

• Become skillful in informal oral case presentations during bedside rounds.
• Enhance formal presentation skills for conferences.

Rounds

Clinical Teaching Rounds are another important component of the 10-week Internal Medicine Clerkship. There are several types of rounds: Teaching Attending Rounds, Bedside Rounds, Teaching Management Rounds, and morning or afternoon Sign-out Rounds. Rounds are conducted similarly at each of the Clerkship Sites.

Teaching Attending Rounds

During Teaching Attending Rounds, the Clinical Teaching relates directly to the patients being managed by the Student Inpatient Care Team. These are Formal Teaching Rounds in which mainly 4th-Year students are asked to present a Patient Case.

Teaching Management Rounds

The Goals for the Team Management Rounds are the same as those of the Teaching Attending Rounds but the Methods and the Participants are different. Either the Chief or Senior Resident, Intern Doctor or 6th-Year Senior Medical Student will conduct a Team Management Bedside Round. Case Management and Decision-Making includes all of the members of the Team for all of the patients on the Team. 4th-Year Medical Students are the primary audience for the discussion and learning associated with the rounds with 6th-Year Students and Interns being the secondary audience. Teaching Management Rounds are at least 2 hours long and occur at least three times per week.

Logbook

Your Logbook is a record of the patients you have seen during the Clerkship. It includes the following items (see  Appendix2):

1. Patient Records: Every Complete History and Physical Examination or Initial Consultation that you perform should be recorded in the appropriate place in your Logbook, followed by a Summary, Problem List, Working Diagnosis, Follow-Up and Discharge Plan. 6th-Year Medical Students are asked to write a Prescription for each Patient Discharged. At the end of the Internal Medicine Clerkship, you are asked to include twenty patients in your Logbook.
2. Procedures: such as Venipuncture, Bladder Catheterisation and others should be recorded in the appropriate place in your Log. When you sign each Procedure, make sure that your senior writes his/her clear name and their signature.
3. Student Seminars: As mentioned above, each student will present two seminars during the 10-week rotation. Your evaluation for these seminars will be included in these seminars.
   Clinical scenario sessions: Each student must include a copy of Clinical Scenario Sessions signed and dated.
4. Attendance sheets: provided by Internal Medicine Course Director, will be attached as well.

Please keep your Logs up-to-date. Once the patients are gone, it will be very difficult for you to describe them accurately.

You are asked to hand in your Logbook during the last week of the Internal Medicine Clerkship. The Deadline is the last Thursday of the Clerkship. Delays are not accepted except for emergency circumstances, which should be notified and later discussed with the Course Director.

Medicine Core Lecture Series

The Medicine Core Lecture Series is designed to supplement student reading and provide additional information, resources and insights into Clinical Practice.

The Lectures are usually held at the beginning of the academic year, in the Faculty of Medicine, 2nd floor, over a period of 6 weeks, after which students will have an MCQ/EMQ Exam related to the lecture content.

The results of this Exam will be part of the total Student Evaluation. Students will be given a copy of the Lecture Schedule no later than the first day of lecturing and periodic updates are provided as needed.
See Appendix 3 for a complete list of lectures.

Recommended Internal Medicine Textbooks

These texts are recommended for basic knowledge of the Practice of Medicine and of Specific Disease States. You should use these texts to read about the cases that you see in the Hospital and Clinics. Refer to Medical Journals to supplement your knowledge of those cases that are not well covered in these texts and to learn more about the latest Theory and Practice. The librarians at the College of Medicine are an excellent resource for help when searching for particular articles or books.
Cecil Essentials of Medicine, 6th edition
Edited by Thomas E.Andreoli, C.J. Carpenter, Robert C. Griggs, and Joseph Loscalzo
Philadelphia: WB Saunders, 2004

Harrison's Principles of Internal Medicine, 16th edition
Edited by Dennis L.Kasper et al
New York: McGraw-Hill, 2005.

Cecil Textbook of Medicine, 23rd edition
Edited by Lee Goldman and Dennis Ausiello.
Philadelphia: Saunders, 2004.

Pocket Reference for Quick Information
Ferri, R.The Care of the Medical Patient, 4th edition, 1997.
Carey C. ed. Washington Manual of Medical Therapeutics, 29th edition, 1998.
Stead L.G.ed.First Aid for the Medicine Clerkship, 2000.
Young, B.ed.USMLE Blue Prints of Medicine, 1997.
Myers, A.ed.National Medical Series (NMS) on Medicine, 2nd edition, 1994.

Valuable Links & Educational Websites

General Information
Question Or Problems

If you have questions about your activities or assignments, or are having problems with any part of the Clerkship, please ask for help from the Clerkship Office. Problems, questions or misunderstandings are usually easily handled if they are brought to our attention.

Clerkship Director Meetings

Once at the midpoint of the Clerkship, and again at the end of the Clerkship, we will meet with you to discuss your evaluations, advise you about your progress, review your logbook entries, and answer other questions and concerns that you might have. Please be on time for these meetings.

Hints For Success In The Medicine Clerkship
Do

• Get involved and work hard. What you get out of it greatly depends on what you put into it.
• Be honest about what you know and do not know.
• Maintain patient confidentiality.
• Behave professionally.
• Remember to launder your white coat.
• Be pro-active. Do phone follow-ups on patients who have been recently discharged from your service or between Clinic Appointments.
• Be prepared. Read ahead for planned lectures, pre-round and obtain outside records.
• Practice your presentations. Do not read your write-up!
• Take advantage of opportunities to be taught. Ask to review x-rays, physical exams, lab tests, etc.
• Ask for feedback.
• Call us if you are having a problem or a concern.
• Ask us if you have a scheduling conflict and do not know what to do.
• Enjoy yourself; Medicine is great fun!

Don't

• Be late.
• Bring coffee or food into a patient's room on rounds or in the Clinic.
• Assume everyone else knows what you do not (they usually do not).
• Put off reading until the last 3 weeks.