Department of Community & Family Medicine
On Doctoring 7963
Geisel School of Medicine at Dartmouth, Remsen 310
Hanover, NH 03755-3833
Phone: (603) 650-6581 Fax: (603) 650-1708
On Doctoring Year One MDED 116
Academic Year 2015-2016
Thursdays, 10:15 AM-12:15 PM
Large Groups meet in Kellogg Auditorium
Small Group meets in Remsen _________
Course Co-Directors:
On Doc Office Hours:
On Doc Class Location:
Roshini Pinto-Powell, MD
Adam Weinstein, MD
8:30 AM – 4:30 PM
Year One On Doctoring sessions meet once a week on Thursdays.
Full Large Group Sessions use the entire On Doc time, from 10:15 AM – 12:15 PM,
All other sessions not indicated are Small Group Sessions, and meet from 10:15AM12:15 PM.
All Large group sessions take place in Kellogg Auditorium unless otherwise noted.
On Doc Staff Emails:
Co-Director Roshini Pinto-Powell, MD: Roshini.C.Pinto-Powell@dartmouth.edu
Co-Director Adam Weinstein, MD: Adam.R.Weinstein@Hitchcock.org
Program Administrator Terri Eastman, M.Ed: Terri.L.Eastman@dartmouth.edu
Course Assistant Cori Stebbins, BS: Cori.R.Stebbins@dartmouth.edu
Facilitator & Preceptor Contact Info:
Facilitator(s):
Facilitator Email(s):
Facilitator Phone(s):
Preceptor:
Preceptor Email:
Preceptor Phone:
_________________________________&_________________________________
_________________________________________
_________________________________________
_ (_____) _______-__________
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_________________________________
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Course Description
On Doctoring is a multi-dimensional relationship centered course which teaches students the knowledge and skills for
effective communication, clinical reasoning, physical examination and ethical care of people. The course is designed to
help the student learn about and practice relationship centered care. The course integrates basic science, social science and
clinical science to provide students with an understanding of the comprehensive basis of clinical medicine. Readings from
the social and behavioral sciences, the clinical literature and medical humanities will broaden the understanding of the
attitudes and beliefs which both patients and doctors bring to the clinical encounter. Small group faculty function as the
students’ primary advisor and mentor, giving them regular feedback on clinical and interpersonal skills.
The course is taught in small groups, using active learning pedagogies. The course fosters a culture of continuous
learning and improvement and students are taught how to work effectively on a team and how to give and receive
constructive feedback. Small groups will use deliberate practice to learn and reinforce newly acquired skills, using role
plays, simulated and real patients in the clinic, hospital and simulation center. In addition, students work regularly in
longitudinal clinical preceptor sites with a primary preceptor throughout phase I of the curriculum. This practice will
enable them to form longitudinal relationships with patients, faculty and communities and further practice the skills
learned in small group. Students will also be exposed to coordinated clinical experiences, including secondary surgical
and subspecialty clinical experiences. Clinical reasoning skills are learned, with a particular focus on how the patient’s
history and physical exam findings influence the diagnostic possibilities in clinical cases.
Course Goals
This course is a multi-dimensional course designed to help you learn the fundamental skills required to develop into a
competent, caring physician. These critically important skills, used by physicians on a daily basis, include medical
interviewing, performing physical examinations, doing written and oral presentations, problem solving, applying medical
ethics, and exemplifying professional behavior. The course has multiple components: small group sessions demonstrating
interviewing and physical exam skills, and clinical work in your primary preceptor’s office. You will also be exposed to a
variety of subspecialty clinical opportunities.
At the end of year one, students will have a basic level of proficiency in fulfilling the following objectives:
1. Demonstrate interpersonal and communication skills that result in effective information exchange,
cooperation and collaboration with patient, patient’s families and professional associates.
a. To demonstrate the ability to be an active listener.
b. To demonstrate an efficient and organized focused and complete interview.
c. To report and record diagnostic information completely and accurately to manage a patient's
biomedical and psychosocial problems completely and accurately.
d. To provide patient education, patient-centered counseling skills, and facilitate behavior
change.
e. To demonstrate the ability to provide compassionate and culturally-sensitive clinical care that
is attuned to the patient’s preferences, goals and life circumstances.
f. Integrate narrative medicine methods to enhance active listening, reflection, and empathy
during patient encounters.
g. To assess and address health literacy in all patient encounters.
h. To demonstrate the ability to have difficult conversations with patients and families.
2. Demonstrate a broad working knowledge of the fundamental biomedical and social science principles,
and processes basic to the practice of medicine and apply this knowledge in a consistent manner to
prevent common health problems and achieve effective and safe patient care.
a. To perform an organized, complete, normal physical exam (excluding GU/GYN) accurately
and efficiently on a classmate or standardized patient.
b. To demonstrate the ability to apply more advanced physical exam maneuvers to elucidate
common abnormalities and pathologies.
c. To perform a focused physical exam guided by the patient history.
d. To demonstrate mindfulness of patient comfort while performing the physical exam.
3. Examine the clinical relevance of scientific inquiry and evaluate emerging knowledge and research as it
applies to diagnosis, treatment and the prevention of disease.
a. To demonstrate clinical reasoning in write-ups and oral presentations through generation of an
assessment including differential diagnosis and plan.
b. To recognize and apply the correlation between basic science concepts and clinical
presentation.
c. To recognize appropriate situations in which laboratory studies and imaging may be required
to supplement the patient interview and physical exam.
d. To demonstrate effective use of patient decision aids to help educate and counsel patients in
common medical conditions.
e. To demonstrate facility with current medical technology in patient education and care.
f. To demonstrate consideration of quality and cost of care, and stewardship of resources.
g. To apply population health concepts in clinical decision making.
4. Produce timely documentation and communication that is clear, concise, and organized in a way that
optimizes patient care and minimizes medical errors.
a. To demonstrate appropriate and effective use of the electronic medical record throughout the
patient encounter.
b. To organize clinical data in clear, concise write-ups using the appropriate format for the given
clinical setting.
c. To prepare and deliver organized, clear, and concise oral presentations using the appropriate
format for the given clinical setting.
d. To demonstrate appropriate reporting of pertinent normal and abnormal findings in both
written and oral forms.
5. Exemplify the highest standards of ethical, professional, and personal behavior.
a. To demonstrate professional and ethical behavior including preparation and active
participation in all aspects of the course.
b. To develop and sustain respectful doctor-patient relationships.
c. To construct collaborative working relationships with other health care providers.
d. To demonstrate professional and ethical conduct as a physician.
e. To assist in creating a safe and respectful learning environment for other learners.
f. To demonstrate the ability to give and receive constructive feedback with peers and colleagues.
g. To demonstrate the ability to apply ethical and legal standards in clinical care, including;
Provider-patients relationship; Shared decision-making; Surrogate decision-making;
Confidentiality; Professionalism.
h. To practice self-directed learning.
i. To evaluate and reflect on your own personal values and attitudes and the influence of these on
your relationships with patients.
j. To describe, through narrative reflection, the impact of a service based learning experience.
k. To demonstrate habits of self-reflection in balancing personal and professional life, personal
reactions to clinical work, and developing your identity as a physician.
l. To demonstrate knowledge of skills and practices to prevent stress, address stress, maintain
resilience and engage in periodic self-assessment evaluating your resilience.
m. To demonstrate familiarity with Cognitive Behavior Therapy (CBT), Mind-body Stress
Reduction (MBSR) and Biofeedback to support your own resilience and enhance effectiveness in
patient care.
Learning Objectives
Becoming a physician requires far more than advanced knowledge and technical skill. Medical training involves growth
in multiple domains beyond the intellectual one. Among them: learning how to manage your emotions, how to function
in the face of uncertainty, how to accept and learn from your mistakes, and how to establish boundaries. The work you
will do is both exhausting and full of joy. You will have the opportunity to participate in the deepest human experiences
that will allow tremendous opportunities for personal growth. The training process is exhilarating but arduous and your
small group, ideally, is a safe haven where you will learn and practice new skills and have the opportunity to reflect on
your development. However, a successful small group requires a commitment from everyone to come prepared to provide
constructive feedback, to set aside prejudices, and to accept differences of opinion.
(Requirements of Year One students to move to Year Two.) By the end of the year each student should have:
1. Prepared for and attended all large and small group sessions.
2. Prepared for and taken all quizzes before the relevant physical diagnosis small group.
3. Attended all preceptor visits.
4. Passed the Year One OSCEs.
5. Submitted the assigned case write-ups to facilitator (and optional to preceptor) by due dates, with a passing grade
utilized by the grading rubric.
6. Documented oral presentations. 2 Oral Presentations should be documented through the use of the OP grading
rubric.
7. Submitted the assigned Cadaver Story and Cultural Essay to his/her facilitator by due dates.
8. Taken a focused history of a standardized patient that is recorded and observed by the facilitator.
9. Demonstrated a physical exam in 30 minutes or less on a classmate.
10. Active participation and documentation of physical examination skills.
11. Met with his/her preceptor to receive feedback and to make plans for improved performance for the second semester
and second year.
12. Met with his/her facilitator to receive feedback and to establish goals for improvement for second semester and
second year.
Teaching Methods
During a typical small group session, the agenda will be written on the board and a timekeeper will be assigned to keep
the group on track. Each group will involve a ten-minute check-in with the group to answer any questions or evaluate any
problems.
Connect 4 (third and fourth year medical students) may also participate in assisting facilitators during small group
sessions on a volunteer basis.
For physical examination sessions, the group will have a volunteer demonstrate the portion of the exam being taught for
that session, or the facilitator will demonstrate a small portion of the exam if there are questions after. Once the students
have no further questions, the group will split into pairs or trios and practice the part of the physical exam and diagnosis
skills they just learned.
For interviewing sessions, the facilitator will briefly explain techniques for interview skills and possibly demonstrate a
portion of the interview taught for that session. Two students will be chosen to practice these interviewing skills on a
classmate, standardized patient, patient bank volunteer, or volunteer patient from your facilitator’s practice. The group
will then debrief. Later, students will practice interviewing skills in pairs and the facilitator will circulate to teach and give
feedback.
For large group sessions, all students will meet in Kellogg auditorium for a large lecture setting. Large group Evaluation
feedback forms will be handed out to each student to fill out evaluating the presenter. (These help the On Doctoring office
with streamlining the topics, presenters, and delivery of information.)
For precepting sessions, the dates for visiting preceptor weeks are located on the schedule. The day of the week that
students will attend their preceptor’s office depends on his/her preceptor’s availability and the student schedule.
Precepting sessions will be scheduled (generally) every week for 3-4 hours each afternoon. (unless otherwise designated)
Expectations
Attendance Policy
On Doctoring follows the same attendance policy as all the clerkships. This policy states that attendance is required for every
On Doctoring session faculty facilitator MUST approve any absence (i.e. if you are going to be out sick, you need to
contact your facilitator ahead of time to let him/her know you will be missing a session). Students also must notify their
preceptor ahead of time to let him/her know you will be missing a session. Students should ask their preceptor how he/she
wants to be contacted.
Clinical Encounter Documentation
It is a requirement by On Doctoring and Geisel School of Medicine at Dartmouth that all clinical encounters are documented.
Medical Education Committee’s Clinical Encounter Goals
The MEC has approved 14 essential clinical skills that you must practice during the On Doctoring first year clerkship, and
then demonstrate your competence to perform the skill prior to completion of the clerkship. Passing On Doctoring will be
based in part on how well you meet these learning targets for practicing these skills, and whether students have demonstrated
an acceptable level of competence in performing theses clinical skills by the end of the clerkship. These core clinical skills
(and learning targets for each) are:
Skill Type
Interview
Physical Exam
Oral Presentations
& Notes
Target #
8
8
8
3
3
3
3
8
8
8
8
5
5
5
Skill
HPI
PMH
ROS
Social History
Family History
Occupational History
Health Maintenance History
Vital Signs
Cardiac Exam
Pulmonary Exam
Abdominal Exam
Skin Exam
Orally Present Ambulatory Encounter
Prepare Field Note
*Please Keep in Mind: You are not required to meet all of these target numbers for goals; they are suggested goals based on
the number of patient encounters. Some students will exceed target numbers in some categories, but lack in other categories.
You will not be penalized for not attaining these target number goals. However, it is absolutely ESSENTIAL that students log
every clinical encounter.
Canvas Learning Platform
Assigned Readings & Syllabus Materials
It is expected that prior to each session the assigned readings and syllabus materials were read and understood. If however,
they are not understood, facilitators can answer any questions during small group check-in. All assignments and their due
dates are located on the course schedule, and are also available on Canvas. The information required to learn for each session
is located in the Advanced Preparation section.
Assignments & Quizzes
It is expected that each assignment be completed on time and submitted to Canvas for grading by your facilitator either on
Canvas or by handing in a print out of the assignment to your facilitator. Facilitators should let you know which method of
submission they prefer. Each due date for each assignment is written on Canvas and the course syllabus. Your facilitator is
expected to give you adequate and clear feedback in a timely manner (generally 72 hours after submission). Your facilitator
may ask you to re-write any inadequate clinical write-ups. Facilitators are asked to submit all grades to the Canvas Grade
book.
In an effort to provide additional, constructive feedback on Clinical Write-ups, they are graded using a rubric system as
shown on Blackboard. As always however, commenting on each write-up is still very important. Scores of 4 or below are
required to be re-done. Students will have two attempts on both quizzes and write-ups to get the best grade.
Year One Clinical Write-Up Grading Rubric
CRITERIA
Exceeds Expectations
Organization  All information
of Write-up
organized in logical
sequence
 Follows accepted
format
 Thoroughly documents
all pertinent history
History
components for type of
note
 Includes relevant
positive/negative ROS,
relevant habits, fam
hx, soc hx
Meets Expectations
 Information generally
organized in logical
sequence
 Follows accepted
format
 Documents most
pertinent history
components
 Includes
positive/negative
ROS
 Thoroughly documents
all pertinent
examination
components for type of
note starting with VS
and general pt
description
 Thorough, welldocumented field note
 Documents most
pertinent examination
components including
VS and general pt
description
4
3
Physical
Exam
Field Notes
Points/
question
Total Score:
16
 Documented field
note
Making Progress
 Information
mostly organized
Needs Improvement
 Confusion about
history vs. physical
 Information
disorganized
 Fails to
document
pertinent HPI
using
OLDCARTS
 Lacks some
critical
information or
disorganized in
chronology
 Documents some
pertinent
examination
components
 Often misses VS
and general pt
description
 Field note
lacking selfreflection
2
 Minimal history
 Critical information
missing
 Physical
examination
inadequately
documented
 Misses several
pertinent
components
 Minimal field note
1
Not Observed
 Student did
not perform
this criteria
0
Year One Oral Presentation Grading Rubric
Oral presentation grading is based on a first year student at the end of year one.
Exceeds Expectations
 All information
organized in logical
sequence
 Follows acceptable
format
 Thoroughly reports
all pertinent history
components for type
of note
 Includes critical as
well as supportive
information
 Reviews all ROS
questions relevant to
the case
Meets Expectations
 Information
generally organized
in logical sequence
 Follows acceptable
format
 Reports most
pertinent history
components
 Includes critical
information
Making Progress
 Errors in format
 Information
intermittently
organized
Needs Improvement
 Errors in format
 Information
disorganized
Not Observed
 Student did not
perform this
criteria
 Fails to report most
pertinent history
components
 Lacks some critical
information or
rambling in history
 Minimal history
 Critical information
missing
 Student did not
perform this
criteria
 Reviews most ROS
questions relevant to
the case
 Thoroughly reports
all pertinent
examination
components for type
of note
 Reports most
pertinent
examination
components
Global
Assessment
 Excellent or
outstanding
performance,
definitely a strength
 Student is already
performing at a level
comparable to a year
two student
4
 Good solid
performance at a
level of mastery
expected for a year
one student
 Fair performance in
this area, but would
benefit from a bit
more practice
 Misses most ROS
questions relevant
to the case
 Some or most ROS
questions are not
relevant to the case
 Physical
examination
cursory
 Misses several
pertinent
components
 Inadequate
performance for the
level of mastery
expected for a year
one student
 Student did not
perform this
criteria
Thoroughness
of Physical
Exam
 Reviews some ROS
questions relevant
to the case
 Some ROS
questions not
relevant to the case
 Reports some
pertinent
examination
components
3
2
CRITERIA
Organization
of
Presentation
Thoroughness
of History
Relevant
Review of
Systems
Points/
question
Total Score:
20
1
 Student did not
perform this
criteria
 Student did not
perform this
criteria
adequately—in
need of
remediation
0
Participation
It is expected that each student actively participate and contribute equally to small group. Discuss small group comfort issues
with your facilitator.
Renting On Doctoring Equipment
Students may check out and borrow On Doctoring Equipment and/or Baskets to practice with by signing them out with
the On Doctoring Office. All equipment and baskets must be put back together in the shape they were found in. Each
group is assigned their own basket. Students may borrow equipment from their group’s basket as long as they sign it out
and return it in a timely manner.
Technology
Technology problems should be reported to the On Doctoring office. If the On Doctoring office is unable to solve your
problem, they will forward you to Geisel School of Medicine at Dartmouth computing at (603) 650-1600.
Geisel School of Medicine Documentation
Before students begin preceptor visits, students must have an up-to-date immunization record. All students must have a
current PPD with in the last year. Students must also obtain a copy of their criminal record check through CERTIPHI. On
Doctoring will provide students with a copy of the current liability rider and letter attesting to your enrollment at Geisel.
Grading
The course is graded Pass/Fail.
Because grades tend to foster competition rather than collaboration, this course is graded pass/fail. Excellent medical care
requires teamwork, and On Doctoring wants to encourage students to work collaboratively in small group. In addition, we
want students to feel as comfortable as possible developing new communication skills, without the pressure of being graded.
The first semester grade will not appear on transcripts. Students will need to successfully complete and receive a passing
grade in all components of the course—preparation, small group participation, preceptor work, and OSCE--in order to receive
a passing grade for the On Doctoring course.
The criteria for passing On Doctoring are …
1. Active, self-reflective participation in all small group sessions and all preceptor visits
2. Demonstrated competency and completion in the following interviewing skills through:
A. Simulations in small group
B. Observations by preceptor
C. Interview with a standardized patient
D. OSCEs
3. Demonstrated competency and completion in physical diagnosis skills through:
A. Participation in small group
B. Completion of written assignments
C. Observations by preceptor
D. Physical exam skills assessment
E. OSCE
4. Demonstrated competency and completion in:
A. Written assignments (Including Cadaver Story, Culture Essay, Clinical Write-ups 1-9, Ethics Presentation)
B. Oral presentations (At least one oral presentation is required per semester; one in Fall, one in Spring)
5. Participation in and completion of required documentation of skills in DMEDs (Dartmouth Medical Encounter
Documentation System).
The criteria for failing On Doctoring may include any of the following …
1. Unexcused absence for more than one small group session.
2. Unexcused absence for more than one preceptor visit.
3. Failure to pass physical diagnosis quizzes
4. Failure to demonstrate competency in physical diagnosis skills through role playing in small group, written
assignments, observations by preceptor and OSCE review.
5. Failure to demonstrate competency in interviewing or oral presentation skills through participation in small group,
written assignments, observations by preceptor and OSCE review.
6. Failure to participate in small groups.
7. Unprofessional behavior as determined by small group facilitator, preceptor and/or course directors.
8. Failure to submit passing patient write-ups. Patient write-ups that "need work" must be revised and resubmitted
for a passing grade.
Opportunities for remediation regarding assignments and competencies will be made available.
Evaluations
Students will be evaluated on their performance formally during mid-year, the end of the year, and informally
throughout the year for self-improvement. Students are evaluated on preparedness, interviewing skills, physical
diagnosis skills, and completion of course objectives, as outlined in the course goals.
The following evaluations are performed of students in Year One:
1. Standardized Patient Interview (Fall)
2.
3.
4.
5.
Mid-Year Facilitator Evaluation of Student (Fall)
OSCEs Checklist & Clinical Skills Competency Forms for OSCE Exams (Spring)
Year-End Facilitator Evaluation of Student & Feedback Session (Spring)
Year-End Preceptor Evaluation of Student (Spring)
The following evaluations are performed by students in Year One:
1. Student Early Preceptor Feedback Form (Fall)
2. Mid-Year On Doctoring Course Evaluation (Fall)
3. Year-End Student Evaluation of Facilitator/Small Group (Spring)
4. Year-End Student Evaluation of Preceptor/Site (Spring)
5. Year-End On Doctoring Course Evaluation (Spring)
Student Needs
Geisel School of Medicine at Dartmouth students are encouraged to seek help through the Student Needs Assistance
Program (SNAP) found at http://dms.dartmouth.edu/students/programs/snap.
Important Numbers
Advising Dean’s Office
Safe Rides
603-650-1755
603-646-8294
Dick’s House
Student Affairs Office
Medical: 603-646-9401
603-650-1509
Counseling: 603-646-9442
DHMC Emergency Mental Health
WISE
800-556-6249
966-348-9473
Log on to Canvas prior to each session for the Advanced Preparation. This section includes required and optional
reading and syllabus materials, websites, and videos that will help with better understanding of the physical exam and
interviewing skills.
Year One On Doctoring Fall Course Outline 2015
Log on to Canvas prior to each session for each week’s Advance Preparation.
Date
Aug. 15
Session Topic
Introduction to On Doctoring
Aug. 22
Aug. 29
Aug. 29
Introduction to Small Groups
8:00-10:00 AM
Facilitator Meeting
Remsen 312
Interviewing Skills & Orientation to
1. Function & Structure of Medical
Cadaver Story
Preceptor Visits
Interview Syllabus
Importance, Structure, and Function of 1. Function & Structure of Medical
the Medical Interview & Introduction
Interview Syllabus
to Vital Signs
Sept. 10
Week of
Sept. 14
Sept. 17
Week of
Sept. 21
Sept. 24
Oct. 1
Week of
Oct. 5
Oct. 8
Week of
Oct. 12
Oct. 15
Oct. 22
Week Of
Oct. 26
Oct. 29
Nov. 5
Week of
Nov. 8
Nov. 12
Week of
Nov. 16
Nov 19
Advance Preparation
Assignments Due
Allied Health Preceptor Visit
History of Present Illness
1. HPI Syllabus
Community Based Preceptor Visit-MI/Coaching Assignment
Questioning Styles & Past Medical
History
Taking a Family & Social History
1. Questioning Styles Syllabus
Culture Essay
1. Taking Family and Social History
Syllabus
Allied Health Preceptor Visit
Introduction to Physical Exam Skills &
the Pulmonary Exam
1. Intro Pulmonary Exams Syllabus
2. Take the Pulmonary Quiz
Pulmonary Quiz
Community Based Preceptor Visit-MI/Coaching Assignment
Introduction to the Cardiovascular
Exam
Introduction to the Abdominal Exam
1. Intro to Cardiovascular Exam Syllabus
2. Take the Cardiovascular Quiz
1. Intro to Abdominal Exam Syllabus
2. Take the Abdominal Quiz
Cardiovascular Quiz
& Clinical Write-Up 1
Abdominal Quiz
Community Based Preceptor Visit
Introduction to the Upper Extremity
Exam
Health Maintenance & Wellness
1. Intro to Upper Extremity Exam
Syllabus
1. Health Maintenance Syllabus
Clinical Write-Up 2
Community Based Preceptor Visit
Practice Physical Exam Skills to Date
Clinical Write-Up 3
Allied Health Preceptor Visit
Practice Interviewing Skills
November 25-29th Thanksgiving Break
Dec. 3
Week of
Nov. 30
Dec. 3
Dec. 10
8:00-10:00 AM
Facilitator Meeting
Vail 513
Community Based Preceptor Visit-MI/Coaching Assignment
Standardized Patient Interviewing
Standardized Patient Interviewing
Dec. 17
Midyear Feedback Sessions
December 18th -January 3rd Holiday Break
1 Oral Presentation
(Due by Dec. 17) & All
Fall Term Course
Work