ALBERT EINSTEIN COLLEGE OF MEDICINE
of Yeshiva University
INTRODUCTION TO CLINICAL MEDICINE
THE CLINICAL EXPERIENCE
CLASS OF 2008
GERIATRIC MEDICINE PROGRAM
TABLE OF CONTENTS
Introduction to ICM and the Clinical Experience .....................................................1
Schedule of Sessions ......................................................................................................2
Faculty .............................................................................................................................3
Geriatric Medicine Program Description ...................................................................6
Student Comments ...................................................................................................7
Objectives
Objectives for the Clinical Experience Course ......................................................8
Objectives for the Geriatric Medicine Program ....................................................8
Course Requirements and Grades ...............................................................................9
HIPAA ...........................................................................................................................10
Faculty Evaluation of Student ....................................................................................11
Student Journal .............................................................................................................12
ICM Introduction to the Patient Assignment
Transcript .................................................................................................................13
Patient Interview Transcript Example .................................................................14
Final Written Assignment ......................................................................................15
Transportation ..............................................................................................................16
Student Guidelines for the Medical Interview ........................................................17
Student Guidelines for the Physical Examination...................................................21
References .......................................................................................................................22
INTRODUCTION TO CLINICAL MEDICINE
THE CLINICAL EXPERIENCE
The Introduction to Clinical Medicine (ICM) Program at the Albert Einstein College of Medicine
aims to teach first year medical students basic skills that are utilized in clinical encounters with patients
including: medical interviewing, relationship building, interpretation and synthesis of patient data, oral
presentation of cases, and case write-ups utilizing standard format. In addition, the program’s goals
include promotion of a biopsychosocial approach to patient care, examination of basic principals of
medical ethics, and identification of personal and societal attitudes and values that influence optimal
patient management.
The ICM program is comprised of three courses, two of which are given in the first year and one
in the second year. The companion course to this first year Clinical Experience course is the Introduction
to the Patient course, which takes place at the medical school on Wednesday afternoons from 1:30 PM to
4:00 PM from September through April in the first year. More than 30 cross-departmental clinical
faculty teach in the course. The second year ICM course, The Clinical Examination, is an intensive yearlong course which teaches physical examination skills and extends the students’ experience with
medical interviewing.
This Clinical Experience course is a 16-session practicum at a clinical site. Each first year student
will participate in one clinical experience, which is scheduled for:
Mondays, September 27, 2004 through February 28, 2005
1:30 p.m. - 4:00 p.m.
All students must attend 2 orientation sessions scheduled for Tuesday, September 7, 2004 and Monday,
September 13, 2004. The orientation session on September 7, 2004 will be held in Riklis Auditorium.
The Observation Skills and Vital Signs workshop on September 13, 2004 will take place in Belfer
classrooms.
1
ICM SCHEDULE 2004-2005
CLASS of 2008
THE CLINICAL EXPERIENCE – Geriatric Medicine
Tuesday, September 7, 2004
Orientation to Introduction to Clinical Medicine
(ICM) – Riklis Auditorium
Session # 1
Monday, September 27, 2004
1st Day at Clinical Sites
Session # 2
Monday, October 4, 2004
Clinical Site Session
Session # 3
Monday, October 11, 2004
Clinical Site Session
Session # 4
Monday, October 18, 2004
Clinical Site Session
Monday, October 25, 2004
NO SESSION – EXAM
Monday, November 1, 2004
NO SESSION – EXAM
Session # 5
Monday, November 8, 2004
Clinical Site Session
Session # 6
Monday, November 15, 2004
AECOM Session – Riklis Auditorium
Monday, November 22, 2004
NO SESSION – EXAM
Session # 7
Monday, November 29, 2004
Clinical Site Session
Session # 8
Monday, December 6, 2004
Clinical Site Session
Session # 9
Monday, December 13, 2004
Clinical Site Session
Monday, December 20, 2004
NO SESSION – HOLIDAY
Monday, December 27, 2004
NO SESSION – HOLIDAY
Session # 10
Monday, January 3, 2005
Clinical Site Session
Session # 11
Monday, January 10, 2005
AECOM Session – Riklis Auditorium
Monday, January 17, 2005
NO SESSION – HOLIDAY
Session # 12
Monday, January 24, 2005
Clinical Site Session
Session # 13
Monday, January 31, 2005
Clinical Site Session
Session # 14
Monday, February 7, 2005
Clinical Site Session
Session # 15
Monday, February 14, 2005
Clinical Site Session
Monday, February 21, 2005
NO SESSION – HOLIDAY
Monday, February 28, 2005
Clinical Site Session
Session # 16
2
GERIATRIC MEDICINE
The program in Geriatric Medicine is designed to expose students to the unique issues
that are faced in providing medical care to elderly people. Students will see patients in a
variety of settings including an ambulatory geriatric practice, home visit program, and long
term care. At their primary sites, students will learn to obtain a complete medical history with
particular focus on issues central to geriatrics. These include the mental status exam, the social
and functional history, and palliative care.
Students will work with a multidisciplinary team and come to understand how health
care professionals from a number of disciplines are required to provide care for the complex
geriatric patient. Students from all sites will be exposed to home visiting as an integral part of
the care of the frail, homebound elderly.
All students in the Geriatric Medicine program will meet for three group sessions
devoted to the central issues of Alzheimer’s disease, depression, and the impact of chronic
illness on the patient and family. The group will explore these issues through interviews with
patients and their families.
The Geriatric Division is a recipient of a Grant for Excellence in the Medical Education
from AECOM. This funding will allow the Geriatric Clinical Experience to offer selected
students the opportunity to have an ongoing relationship with a community dwelling older
person. These encounters will occur in the older person’s home and will introduce the concept
of healthy and successful aging into the curriculum.
The program is coordinated by Amy Ehrlich, MD and takes place at 7 sites:
Montefiore Medical Center
Kittay House, (Bronx)
Geriatric Services, PC (Yonkers)
Beth Abraham Comprehensive Care Management, (Bronx).
Beth Abraham Family Health Services
Sarah Neuman Home, (Mamaroneck)
AECOM Faculty Practice/Weiler Hospital
This program can accommodate 18 students.
3
GERIATRIC MEDICINE
Quotes from the Students in the Class of 2005:
“There was a great deal of extended patient contact and interview time.”
“I would highly recommend geriatrics. It seemed unappealing in the beginning, but it got
more and more interesting. Because the pace was a bit slower, we got a deeper and more
detailed exposure to patients’ medical, functional and emotional & psychological issues.”
“This program is an incredible experience. Even if the field of geriatrics does not interest you
per se, the exposure to patients and the excellent physicians make this an amazing
experience.”
“The program gives a lot of chances to interview. We got to work with different health
professionals in geriatrics, not just the doctors. “
“The variety of experience was directly related to the enthusiasm of the preceptors. In
addition to my usual clinical site, we went on a home visit to interview the patient in their
own environment. We also went to the inpatient unit at Montefiore.”
“It was not my top choice, but much better than I expected – similar to the GMP, but in
Geriatrics. I was surprised to learn about dementia and depression, and the complicated issue
of drug interactions.”
Quotes from the Students in the Class of 2006:
“A great experience even if you don’t want to go into geriatrics.”
“There were a lot of opportunities to talk with patients and really polish my interviewing
skills.”
“The geriatricians do an excellent job of teaching & training the appropriate and necessary
skills of patient interviewing, and organizing and orally presenting a case.”
“My preceptor’s rapport with her patients was really wonderful and showed me how a good
relationship between physician and patient can lead to trust and better care overall.”
4
Objectives for the Clinical Experience Course

To experience working in a clinical setting.

To learn the organizational structure of a clinical service.

To participate in the health care of patients.

To experience taking a medical history.

To experience performing simple physical examination procedures.

To experience working with other health care professionals.

To learn to communicate effectively with other health care professionals.
Objectives for the Geriatric Medicine Program

Learn to obtain a complete medical history from an elderly patient

Appreciate the complex factors involved in maintaining independence for an elderly
patient, including their functional status and social support network

Evaluate the mental status of an elderly patient using the Folstein Mini-Mental Status
Examination

Understand the role of each member of the multidisciplinary team

Gain an initial understanding of three key topics: Alzheimer’s Disease, depression in
the geriatric population, and the impact of chronic disease

Understand the concept of palliative care
5
Course Requirements and Grades
•
Attendance is required at all scheduled sessions and will be factored into your final
evaluation. If you are unable to attend a session for any reason, it is expected that you
will follow professional protocol and contact your preceptor prior to the session.
•
The course is graded on a Pass/Fail basis. Each student will receive a written
evaluation from their preceptor at the conclusion of the course. Students are evaluated
on the development of clinical skills, motivation for learning and attendance. Poor
attendance or unauthorized absences will result in a failing grade.
•
Students must keep a journal of their experience, preferably on a weekly basis. Journal
entries will be needed at the end of the year to help students prepare the final
assignments in the Wednesday course, Introduction to the Patient.
•
Each student should dress in a manner which is consistent with traditionally accepted
professional standards. White coats and name-tags are generally expected.
•
Each student is expected to assume responsibility for his/her learning at each site. This
requires ongoing discussion between students and preceptors regarding the courses’
objectives and how the objectives can be met or adapted at the clinical site. Students
should also actively seek out opportunities which may be available beyond their usual
activities and be proactive about requesting participation.
6
The Health Insurance Portability and Accountability Act of 1996
(HIPAA)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a
federal law designed to improve the efficiency and effectiveness of healthcare
nationwide. The “portability” component of HIPAA protects health insurance coverage
when workers change or lose their jobs. The “accountability” component establishes
mandates for the security and privacy of patient information. This accountability
applies to all health care providers.
As of April 14, 2003 all people who work in patient care settings including
doctors, nurses, administrators, security, volunteers, and others must show proof that
they have received education about the HIPAA regulations.
As medical students, you will have direct contact with patients, and are subject
to the provisions specified in the legislation. One of the ways that institutions such as
Einstein have to assure that it’s members are compliant with the HIPAA regulations is
by providing adequate training.
You will be notified regarding where and how you can satisfy this requirement.
7
ALBERT EINSTEIN COLLEGE OF MEDICINE
INTRODUCTION TO CLINICAL MEDICINE: THE CLINICAL EXPERIENCE
FACULTY EVALUATION OF STUDENT
Student
AECOM Class
Clinical Program/Site
2008
2004-2005
Date _________________
Preceptor(s)/Mentor(s) _________________________________
Directions: Given that this student is in the first year of medical school, assess the students’ performance at your site for each of the behaviors
listed below. Return to the ICM Office, Belfer 507, in an envelope marked CONFIDENTIAL. To safeguard against loss in the mail, please make a
photocopy before returning it to the medical school.
Outstanding
Satisfactory
Needs
Improvement
Not
Observed
CLINICAL KNOWLEDGE AND SKILLS
Acquisition of beginning medical interviewing skills
Organization and thoroughness of oral case presentations
Acquiring knowledge of...
The importance of psychosocial issues
Some common medical and/or social problems
seen at your clinical site
The application of the basic sciences to clinical practice
Judgment in clinical situations...
Ability to understand limitations of the student role
Beginning ability to prioritize tasks and clinical data
INTERPERSONAL/PROFESSIONAL CHARACTERISTICS
Interpersonal relationships with...
Patients and families
Preceptors(s)/Mentors(s)
Other clinical providers and personnel
Attendance and participation
Motivation and Industry
Ability to accept direction and/or criticism
COMMENTS: Please describe (with examples) the student’s strength(s) and weakness(es), including suggestions for areas of improvement.
Discussed with student?
Yes
No
Signature_________________________________________________
8
THE CLINICAL EXPERIENCE
STUDENT JOURNAL
WEEK OF:
______________________________
PATIENT DATA
AGE:
SEX:
ETHNICITY:
Presenting Problems:
Ongoing Psychosocial Issues:
WHAT WAS YOUR ROLE: (circle one)
Observe
Interview
Examine
Describe:
Notes/Learning Needs:
SUMMARY: (Describe your impression of the patient encounter, what you have learned, etc.)
PRIVATE THOUGHTS AND OBSERVATIONS OF THE DAY
9
Introduction to the Patient (Course) Assignments
All students are required to complete two assignments for the Wednesday, ICM course,
Introduction to the Patient. Preceptors for the Clinical Experience have no direct responsibility for these
assignments. However, student interactions with patients at the clinical site form the basis for both
assignments. The descriptions of each assignment follow below, pp. 12-14.
Instructions for the Patient Transcript Assignment
For Wednesday, December 3, 2003
For this session, you must interview a patient (or parent, if patient is a child) at your Monday,
Clinical Experience site. This interview must be done by you individually, not in tandem with another
student. The interview should be at least 10 minutes long and may cover any aspect of the patient’s
history. If you have access to an audio tape recorder, and can obtain permission from the patient to
record the interview strictly for the purposes of this assignment, that would be helpful. If you cannot
audiotape the interview, immediately following the interview (within minutes), write a literal transcript
of the encounter using the format provided in the example on the following page. Waiting to write the
transcript, even for a little while, will severely affect your recall and the quality of your effort. If you
have audiotaped the interview, you can prepare the transcript at your leisure.
1. In the left column of the transcript, record what the patient says, including facial expressions and
relevant body language.
2. In the middle column, record what you said, also including non-verbal behaviors.
3. Stagger the quotes so that the sequence of the interview is easy to follow.
4. In the right-hand column, analyze the interaction between you and the patient; commenting on
your use of strategies for a) building a relationship and b) information gathering.
5. Look for moments during the encounter when you could have used a strategy, but did not.
Discuss how the tone, content, or relationship could have differed had you used the strategy.
6. Comment on your personal reactions to the patient; his/her statements, attitudes, beliefs or
behaviors during the encounter.
This written transcript, like all write-ups for the course, requires that you maintain the patient’s
confidentiality by using initials only. Bring the transcript to your Wednesday group. For the group,
come prepared to discuss your use of the strategies and where you are in the progression of building
your interviewing skills.
REMEMBER:
You must bring the written transcript to the Wednesday small group,
Dissecting the Clinical Encounter.
10
Patient Interview Transcript Example
Patient Statement
Student Statement
Interaction Analysis
Hello Mrs. S., I’m _____.
Are you the doctor?
I’m a medical student here at the
clinic
When will I speak with the
doctor?
I’ll be speaking with you for a few
minutes before the doctor joins us.
I got off to a poor start because I
didn’t introduce myself properly, or
give the patient enough information.
I saw from the patient’s facial
expression (annoyance) that
rapport building was made more
difficult because of my gaff.
Oh, I see. What do you want to
ask me?
Later in the interview…
I’ve been wondering what could
be causing this sharp pain I
sometimes have in my stomach
(patient looks worried)
I’m sure the doctor will ask more
about that when she comes in.
To get back to that sore throat you
mentioned…
I thought I was being empathic
here, but I guess the patient didn’t
see it that way.
But, do you have any idea what
could be causing the pain
(patient biting her fingernails)
Like I said, the doctor will be in
soon.
I know I’m probably sounding
silly with my worry.
Not at all, I can hear your concern.
Finally the patient got through to me
and I came up with an empathic
statement.
Most people experiencing a
significant pain would be
concerned.
Legitimation
What else can you tell me about the
stomach pain?
Open-ended question
11
STUDENT JOURNAL/FINAL WRITTEN ASSIGNMENT
FOR WEDNESDAY, MARCH 24, 2004
We are providing a student journal form on the following page to make it easy for you to record your
observations & comments about the patients you see in your Monday afternoon clinical experience. We
suggest that you duplicate this form as needed and compile them in a folder or notebook. This journal is for
your use only and will NOT have to be collected or inspected by anyone else.
Nevertheless, we urge you to use the journal to write down your successes, failures, frustrations, and
reflections on your first clinical experience in the role of medical student. Experience will demonstrate that
recall alone will not suffice, details will fade and patient histories and situations will begin to merge. A written
record will greatly assist you in preparing the final written assignment for the Wednesday afternoon,
Introduction to the Patient course.
For the last small group session in the Introduction to the Patient Course scheduled on Wednesday,
March 24, 2004, you must write a 3-4 page paper describing and analyzing an event or events that occurred
during your Monday clinical experience that enhanced your understanding of the doctor/patient relationship
and/or your own personal growth as a professional and a physician.
SUGGESTIONS FOR TOPICS
These suggestions are listed randomly.
Topics for your paper are not limited to the examples provided.

Clinical scenario(s) in which you perceived either the patient's and/or the provider's (physician, resident,
nurse, medical student) cultural background enhanced or detracted from the quality of care.

Clinical scenario(s) in which you perceived the quality of care was improved or worsened by another
factor (age, sex, gender, sexual orientation, language issues, socioeconomic factors).

Ethical issue(s) which affected the doctor/patient relationship or the provision of care.

Exemplary behavior or attitudes by your preceptor/mentor in the context of the clinical encounter which
you would like to emulate in your clinical practice.

Your attitudes or belief systems about patients or cultures which were challenged or changed by your
clinical experience.
12
TRANSPORTATION
Transportation to clinical sites occurs in different ways. Some sites are within walking
distance from the AECOM campus, others are served by the AECOM shuttle system. Most
students travel via taxis contracted by the medical school. Students do not pay out-of-pocket
for taxis. Travel by taxi is arranged through the AECOM transportation office. As with any
transportation system, sharing of taxis and delays may occur. However, students who have
cars and are willing to car-pool have usually found that option easier and quicker.
Students placed at sites within walking distance or served by the AECOM shuttle MAY NOT
DRIVE. If you plan to use your car, you must agree to drive other students from your site and
you must notify the ICM office of your intent.
Keep in mind that once the semester starts, your choice of transportation should remain the
same for the duration of the course. If you plan to drive, reimbursement of travel expenses by
AECOM is limited to bridge or tunnel tolls and parking. Receipts (including E-ZPass monthly
statements) are mandatory for any reimbursement.
13
STUDENT GUIDELINES FOR THE MEDICAL INTERVIEW
This Monday afternoon clinical experience is organized to allow you to practice elements of the
medical interview that you are studying concurrently in the Wednesday afternoon ICM course,
Introduction to the Patient.
For clinical encounters with patients, it is important to keep in mind that the medical interview has
two main elements: structure and function. The goals of the first-year ICM courses are for students to
understand and begin to develop proficiency in both of these elements.
STRUCTURE
The structure of a medical interview can be described broadly as the opening phase, the body of the
interview, and the closing phase. The Cole and Bird text states:
“The opening of the interview can be broken into five components. There are of course many different
ways a skilled clinician can open an interview with a patient. The following format represents just
one approach that is usually effective in laying the groundwork for a therapeutic doctor-patient
encounter.”i
1.
2.
3.
4.
5.
Introduction
Establishing goals of the interview
Obtaining patient consent to your interview plan
Establishing initial rapport
Establishing patient comfort
FUNCTION
For the body of the medical interview, you are encouraged to use patient-centered communication
techniques using open-ended questions and active listening skills to encourage patients to tell their
stories in their own words. However, you will need to ask some closed-ended questions to clarify
time-frames and details of patients’ symptoms. Since you are beginning medical students and have
limited knowledge of basic pathophysiology, eliciting information about the patient’s primary
symptom or “chief complaint”, can be difficult. It is helpful to structure your inquiry about each
symptom by asking about the seven core attributes of any symptom. Knowing these attributes or
dimensions of the symptom will help you discern patterns of illness and establish diagnostic
possibilities.
1.
2.
3.
4.
5.
6.
7.
Location
Quality
Severity
Timing
Context
Modifying Factors
Associated Signs and Symptoms
14
The closing phase of the interview is sometimes “rushed” or minimized in clinical practice. However,
the closing phase serves several important purposes.
“The end of a particular interview is a heightened time. Persons remember best the first
things that happen (the “primacy” effect) and the last things that happen (the “recency”
effect). Closure can add power to the interview or undermine good work. The ending
creates a connection to the next visit and contains within it the seeds of the next
opening.’ii
The closing phrase should include: eliciting further information, eliciting patient questions, checking
patient comprehension, summarizing plans for what will happen next, and offering support and
encouragement for adherence or behavior change.
For a more complete understanding of the above structural elements, please refer to the text, The
Medical Interview: The Three-Function Approach.
There are three functions of a medical interview. The Cole and Bird text states:
“By using the interview as a clinical tool, the skilled physician strives to accomplish three broad
objectives [functions]: (1) to establish and maintain an effective doctor-patient relationship; (2) to
diagnose the patient’s problems; and (3) to educate and motivate the patient to cooperate with
treatment recommendations.”i
The primary focus in the first-year ICM courses is on functions 1 and 2. Skills related to function 3
are generally acquired at later stages of training. Below is a summary of the communication
strategies useful for addressing each function of the interview. These communication techniques
should be woven throughout the structure of the medical interview. You should specifically practice
these communication skills with the patients you interview in the Clinical Experience course on
Monday afternoons.
15
Function I
Relationship Building – The purpose is to listen for feelings and respond actively as a way to
encourage trust and facilitate the other functions.
Strategies:
P partnership –
E
A
R
L
S
joint problem solving, conveying a sense of working together with the
patient
empathy –
actively communicate understanding of the patient”s feelings in spoken
response or by non-verbal behaviors. Reflecting feelings back to the patient
in words.
apology –
show concern for “faux pas,” hurts, bumbles, misunderstandings and
mistakes. Show compassion regarding the patient’s illness, injury, problem,
etc.
respect –
communicate that you value the patient’s choices, traits, behaviors and
backgrounds.
legitimation – normalize and validate a patient’s feelings, response and choices.
support –
actively offer ongoing support for the patients that conveys an attitude of
non-abandonment.
Function II
Information Gathering – The purpose is to elicit the patient’s biomedical and psychosocial data
accurately, completely, and efficiently.
Strategies:
The “exhaustive what else?”–
Joint agenda setting Open-ended questions –
Facilitating –
Clarifying –
Checking and summarizing
prompt the patient to relate as complete a reporting of the
problem or situation as possible, telling you everything they
can. Also, seek the patient’s entire agenda.
negotiate priorities together, share control, and establish the
concepts of limits.
invite the patient to use judgment about which problems to
prioritize, to decide how to begin the explanation of a problem
and what specific information to relate.
encourage patients to tell their story in their own way, to
convey a sense that you, the doctor, wish to fully understand.
seek specificity and clarity.
seek an accurate understanding, assure the patient that he/she
has been heard, invite further clarification.
16
GUIDELINES FOR ORAL AND WRITTEN CASE PRESENTATION
Use the traditional structure of organizing the medical history for written and oral presentations.
Your preceptor should help you to learn which elements of the history should be presented under
which headings. The following headings are the ones you are expected to use:
HISTORY
Identifying Data
Chief Complaint
History of Present Illness
Past Medical History
Family Medical History
Social History (Current and
Past)
EXAMINATION
Description of the Patient
Mental Status Examination
ASSESSMENT
Patient’s Understanding of Illness
Assessment and Plan
Note: You are not expected to conduct or present a Review of Systems (ROS) nor are you expected to
conduct or present any aspects of the physical examination. These tasks are learned in the second
year ICM course, The Clinical Examination
.
i
The Medical Interview: The Three-Function Approach, Second Ediction, by Steven A. Cole and Julian Bird, Mosby, St. Louis, 2000.
The Medical Interview: Clinical Care, Education, and Research, by Mack Lipkin, Jr., Samuel M. Putnam, eds, Springer-Verlaq,
New York, 1995.
ii
17
STUDENT GUIDELINES FOR THE PHYSICAL EXAMINATION
The primary goals of this Clinical Experience course for first year students of the Albert Einstein
College of Medicine (AECOM) are to begin to practice medical interviewing and case
presentation skills. Students at the first year level have not completed any courses in anatomy,
pathology, or microbiology and do not formally study techniques of physical examination until
the second year. Therefore, physical examination of patients is not stressed in this course.
First year medical students do not have the in-depth understanding of infection control
measures that comes from knowledge of the basic sciences gained over the first two years of
medical school. Thus, they are unable to make fully informed decisions about how to protect
themselves from harm while examining or conducting procedures on patients.
Any physical examination skills that are taught in this course, should be simple skills such as
taking vital signs or listening to respiratory or heart sounds. Under no circumstances should
students at the first year level perform any invasive procedures on patients including blood
drawing, starting IVs, minor (or major) surgical procedures and pelvic or rectal exams.
Appropriate technique for performing these procedures using universal precautions will be
formally taught to the entire class of AECOM students in ICM during the second year Clinical
Examination course.
18
References
Rowe J, Kahn R. Human Aging: Usual and Successful. Science. 1987;237:143-149
19