FM 620 Family Medicine Elective Family Medicine Sub-Internship in Community Health

Introduction 

The Family Medicine Sub-Internship Elective Clerkship is in Community Practices and Community Health Centers (CP-CHC) for the underserved throughout Michigan. The purpose of this clerkship is to give the fourth year medical student the opportunity to be involved in the care and management of patients. Medical students will select the site of the clerkship in coordination with the Family Medicine Department (FM) in East Lansing. All sites must be pre-approved through FM, prior to the start of the clerkship. Relocation will be necessary for many of the CP- CHC. Some sites are able to help with relocation lodging. The student will be involved in providing first line care for patients for seven half-days per week. The remaining three half-days will be used for a complementary, mentored scholarly project (with FM faculty supervision through distance technology) where the student will be studying how to better the health and medical conditions of patients in the clinic. This project will be presented to FM faculty.

Educational Goals 

The goals of the clerkship are:

1.     To manage a small number of patients as the first line of care

2.     To provide care in medically underserved communities

3.     To study and develop a plan of improvement of a community health or medical problem

Educational Objectives 

Students who have completed this clerkship should be able to:

  • Perform the diagnoses and understand the medical management necessary of patients at an entry residency level that will improve the medical student’s transition into residency.
  • To provide experiences, knowledge, and understanding of medical services to the underserved.
  • Conduct appropriately focused history and physical exams.
  • Develop, prioritize and justify differential diagnoses.
  • Develop treatment plans that include clinical evaluation, treatment and follow-up that meet the patient and family preferences.
  • Understand and use principles of evidence based medicine as it applies to patient care.
  • Understand and apply concepts of population medicine in the care of a community and its medical and health concerns; and, to develop a population health improvement project that addresses critical community medical problems.
  • Understand and utilize other disciplines in the appropriate patient care.

Activities 

  • Clinical: Seven half-days in clinical care participation; and one weekend of call (at least).
  • Didactics: Individually scheduled with FP faculty mentor through telephone, computer contacts.
  • Oral Case Presentation: At the end of the fourth week the student will present findings of the population-based health project to the FP faculty.

Text 

Roadmaps for Clinical Practice: A Primer on Population-Based Medicine by KE Peters and AB. Elester. Chicago, IL: American Medical Association. 2002. (available in department office in East Lansing, see Joy Hull)

Professional Behavior 

Department and College Policies 

Students in the FM Sub-Internship Elective Clerkship are expected to demonstrate appropriate professional behavior in all clinical and academic settings. This includes appropriate dress, punctuality, respect, courtesy and helpfulness toward all patients, preceptors, teachers, staff and classmates; responsibility for knowledge of the content of the clerkship syllabus, schedules, verbal instructions and clerkship memorandum; timely completion of all components of the clerkship. You are also expected to adhere to the Student Oath you took when you matriculated into the College of Human Medicine and to the Principles of Professional Behavior (See Block III Junior Handbook for detailed explanation.)

Appropriate Dress 

Appropriate dress is required which includes: ties for men, hair controlled, nails clipped and clean, etc. Clearly, individual judgment is involved in choosing appropriate dress for clinical experiences. Student appearance including clothing and grooming should communicate respect for the patient and the activity. Blue jeans, shorts, dirty athletic shoes, extremely short skirts, or low-cut blouses are examples of inappropriate dress for activities involving patients.

Attendance 

Students are required to attend all components of the clerkship experience. These components are discussed during the clerkship orientation. Should any others be added during the clerkship, the preceptor will notify students. Attendance at all scheduled activities during the clerkship is mandatory. If a student is unable to attend any activity of the clerkship due to extenuating circumstances, the student is responsible for contacting the lead preceptor to obtain permission for the absence. It is expected that time missed during the clerkship will be made up. Absences of more than two and a half (2-1/2) days will result in the student repeating the clerkship. Unexcused absences will be considered unprofessional behavior and will be noted as such by the Associate Chair for Academic Affairs on the clerkship letter.

Students are excused from clerkship activities during the official University-designated holidays (Memorial Day, 4 th of July, Labor Day, Thanksgiving Holiday, Christmas Holiday, New Year's Holiday and Martin Luther King Day). In keeping with the university policy on religious observances, faculty will honor student absences and requests for make-up opportunities when clerkship activities fall on religious holidays. In the event that the presentation is scheduled on a religious day that is of personal significance, the student should submit a request for an excused absence to the FP faculty mentor.

CHM Guidelines regarding CMS (Centers for Medicare and Medicaid) rules and the medical student 

The CMS rules are intended only for the physician that bills for the visit, not those that assist in the care (i.e. the student). This rule does not prohibit the student from documenting any part of the patient visit. In fact, a medical student may document any or all of the three components (history, examination, medical decision making) required for a patient encounter. These components are important for students to conduct and should appropriately remain a part of the patient’s medical record.

However, CMS is paying for a physician to see their patient and wants the services to be provided by the physician. Therefore, the teaching physician may NOT refer to a medical student’s documentation in order to bill at a particular level (With the exception of the 1) review of systems, and 2) past family, social history).

The teaching physician may verify and must re-document the history obtained by the student. All other components (history of present illness, physical examination and medical decision making) must be performed and RE-DOCUMENTED by the teaching (billing) physician. The depth and extent of the student’s documentation is irrelevant. This rule also applies to the documentation by other kinds of students (i.e. physician assistants and nurse practitioners).

HIPPA training in patient confidentiality 

The Primary Care Clinic may require the student to complete its training regarding HIPPA. The student will be notified at orientation what the individual CP-CHC policy is.

Evaluation 

  • The student will be evaluated on the standard clinical performance evaluation (CPE) for fourth year medical clerkship (see appendix). This will be submitted to the East Lansing Family Medicine Department, CHM/MSU for the final elective letter for the student’s file. If the medical student is from another university, the CPE will be sent to the place designated by the student.
  • Part of the final evaluation will be based on the completion of the oral presentation as well as the clinical work.

Grading Criteria 

  • Clinical performance with patients, staff and faculty.
  • Oral presentation of the population-based medicine project.
  • Pass/fail

Credits 

A four-week elective clerkship is six credits. The clerkship can be taken twice for a total of 12 credits.

Details of the Program Activities 

Didactic Sessions: To be determined by the project the student selects.

Oral Presentation: Instructions will be provided at orientation.

Write-ups: Instructions will be provided at orientation.

Schedule 

The typical day will be spent in clinical practice with patients of the community; faculty supervision will be throughout the day with an opportunity at the end of the day for further faculty and student discussion. The half-days away from clinical practice in preparation of the project will be spent at the direction of the student with guidance by the FP mentor. At least one weekend of on-call will be a part of each four-week clerkship.