Guide for Family and Community Medicine Clerkship Preceptors

This guide briefly summarizes responsibilities of Family and Community Medicine Clerkship preceptors. More specific information can be found in the student syllabus that is available online at http://www.bcm.edu/familymed/?pmid=8313. Click on Clerkship Handbook. To further enhance your teaching ability and skills, we encourage you to access and read references that are mentioned in the footnotes of each page.

TABLE OF CONTENTS I. II. III. IV. V, VI. VII. VIII. IX. Clerkship Personnel Goals and Learning Objectives Assignment of students Student schedule Orientation of your student Patient Care and other learning experiences Teaching and learning Feedback Evaluation Page 2 3 3 4 4 5 6 7 7

I. Clerkship Personnel Please contact any of the individuals below for questions about the clerkship or if you have anything you wish to discuss about an individual student. William Y. Huang, M.D., Director Family & Community Medicine Clerkship Phone: (713) 798-6271, (713) 861-3939 Fax: (713) 798-7789 Pager: (281) 952-4384 Email: williamh@bcm.edu Carolyn Olson Preceptor Coordinator Phone: (713) 798-6590 Fax: (713) 798-5795 Pager: (713) 509-6931 Email: colson@bcm.edu Elvira Ruiz Course Coordinator Phone:(713) 798-8028 Pager: (713) 764-5825 Fax: (713) 798-5795 Email: eruiz@bcm.edu

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II. Goals and Learning Objectives Clerkship goals and objectives: Please see syllabus for a list of clerkship goals with more specific learning objectives for each. Goals are organized according to the six ACGME competency categories of patient care, medical knowledge, professionalism, interpersonal communication, practice-based learning and systemsbased practice. Major emphases of the clerkship: Enable students to: Learn the process of ambulatory care using the Task-Oriented Processes in Care (TOPIC) model1,2,3 which teaches students the tasks to perform in accomplishing different types of ambulatory visits. Gain knowledge and skill in diagnosing and managing common ambulatory conditions (See Appendix III of the syllabus for a specific list of conditions) Gain skill in self-learning using evidence-based resources such as handheld computers Your learning objectives for the student: You may share additional learning objectives for the student. (Please see section IV. Orientation on discussing those with the student) Learning objectives should be SMART: Specific, Measurable, Attainable, Relevant, and Time Framed. 4 Your student may also have learning objectives. III. Assignment of students There are 12 four-week rotations throughout the academic year from July to June Our preceptor coordinator, Carolyn Olson, will contact you in advance so that you may pre-select which rotations you wish to serve as a preceptor During the week prior to the rotation that you have agreed to precept, Carolyn Olson will notify you of your students name via email or phone.

Rogers J, Dains J, Corboy J, Chang T. Curriculum renewal and a process of care curriculum for teaching clerkship students. Family Medicine 1999 Jun;31(6):391-7. http://stfm.org/fmhub/Fullpdf/june99/mse.pdf 2 Rogers J, Corboy J, Dains J, Huang W, Holleman W, Bray J, Monteiro M. Task-oriented processes in care (TOPIC): a proven model for teaching ambulatory care. Family Medicine 2003 May;35(5):337-42. http://stfm.org/fmhub/fm2003/may03/Rogers.pdf 3 Rogers JC, Corboy JE, Huang WY, Monteiro FM. The Task-oriented Processes in Care (TOPIC) Model in Ambulatory Care. New York, Springer Publishing Company, 2004. 4 Stuart MR, Krauser PS. Using goals and objectives in the community family medicine rotation. Family Medicine 1997;29(2):92. Available at: http://stfm.org/teacher/1997/feb/feb.html Version 1.1, October 2007 3

IV. Student Schedule The student schedule varies depending on whether you practice in the greater Houston area or are outof-town. Preceptors in the greater Houston area Preceptors outside of the greater Houston area All students attend a series of orientation seminars on the first Monday morning of the Clerkship Preceptor time Students may choose to stay in Houston on the first Monday afternoon to view video resources. begins the first Monday afternoon continues through the Tuesday afternoon of the Students are granted travel time during daytime fourth week hours at the beginning and end of the clerkship Exception: students will not be in your offices Depending on the distance traveled, preceptor on Thursday afternoons. (see below) time begins sometime on the first Tuesday Preceptor time continues until Tuesday of the fourth week. (Please allow travel time back to Houston for Wednesday morning exam.) Students attend Longitudinal Ambulatory Care Students do not attend LACE course activities and Experience (LACE) course activities every stay in your office on Thursday afternoons Thursday afternoon All students have a series of examinations and seminars on the fourth week of the clerkship, from Wednesday through Friday afternoon Attendance at all ambulatory care sessions: We expect students to be present whenever you are in the office seeing outpatients (including Saturday mornings) (except for those attending LACE activities on Thursday afternoons). Other weekday activities: During weekdays, they may accompany you to make hospital rounds and nursing home rounds, but they are not expected to do these types of activities on the weekends The syllabus gives more specific information on other aspects of their schedule. Illness or personal emergency: Students are excused if they are ill or have a personal emergency. However, they are instructed to contact both you and our Clerkship coordinator, Elvira Ruiz, in order for the absence to be considered an excused absence. Please contact Elvira Ruiz or Carolyn Olson immediately if your student is absent and you do not know his/her whereabouts. If a student has excused absences that total more than 10% of clerkship time (2 days), he/she may be asked to make up part of the time Unexcused absences are considered a breach of professionalism that may result in a lower grade or a failing grade on the clerkship Holidays: Baylor College of Medicine observes the following holidays: Martin Luther King Day, Presidents Day, Good Friday, Memorial Day, Independence Day, Labor Day, Thanksgiving and the day after Thanksgiving, Christmas Eve, Christmas and New Years Day From our perspective, students may be excused from clinical responsibilities on any Baylor holiday, but if your office will be open on a Baylor holiday during their rotation, they have been instructed to ask you for permission also.

V. Orientation of your student Please take time to orient your student to your office and the clerkship. The following items can be discussed5: Discussion of learning objectives:
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Steele DJ. Orienting medical students in community-based teaching sites. Family Medicine 1997;29(9):614-5. Available at: http://stfm.org/teacher/1997/oct/oct.html Version 1.1, October 2007 4

Clerkship learning objectives Your learning objectives Students learning objectives Learner contracts6 are an option to formalize expectations for the student, but are not required. How teaching and learning will occur in your office, including your role and the students role. A staff member can perform additional parts of the orientation: Your office layout and specifics of your office operation Work area for the student: Where student can work and store his/her belongings, etc. Computer/Internet access if available

VI. Patient Care and other Learning Experiences Allow students to see patients independently: After observing you conduct a few patient encounters, please give your student the opportunity to see patients independently. Immediate availability of supervision: Please be present in the office when the student is seeing patients Choose appropriate patients: Please select patients that will allow the student to conduct focused encounters in the ambulatory setting and meet learning objectives. (Avoid complex patients in the beginning of the clerkship.) Students are required to see specific, but common clinical conditions in your office. (See Appendix III of the syllabus). The student will ask you to document that he/she has seen each of these on a beige card. Gain the patients permission beforehand for the student to be involved in the encounter: (Your staff member can do this.) Student involvement in examining the patient: Students may perform routine parts of the physical examination independently. However, please do not allow a student to conduct a breast, pelvic, rectal or prostate examination without you (and a chaperone if appropriate) being present Student involvement in procedures: The student may assist you in performing office-based procedures, but please do not allow a student to independently conduct an office procedure without your being in attendance to supervise. Universal precautions: Please provide appropriate equipment (masks, gowns, gloves, etc.), so that students can follow universal precaution guidelines when seeing patients in your office In the event of a hazardous exposure, students are instructed to contact us and also the Baylor Occupational Health Clinic and follow their recommendations (including a visit to that clinic if needed.) Student notes in the medical record: You may decide if students write a note in the official medical record (paper or electronic) or write an unofficial note that is not included in the medical record. There are advantages and disadvantages to each of these methods. 7 In either case, the goals are that: students learn to write a focused note reflecting the ambulatory encounter students independently think through the assessment and plan as far as possible. If students write in the official medical record, it is imperative for you to carefully read the students note and make sure everything is correct and in accordance with what you write in your own note.
Ferrante J. Learner contracts. Family Medicine 1998;30(10):703-4. Available at: http://stfm.org/teacher/1998/novdec/novdec.html (Scroll to the second-half of the webpage). 7 Chappelle KG, Blanchard SH,Ramirez- Williams MF, Fields SA. Medical students and Health Care Financing Administration documentation guidelines. Family Medicine 2000 Jul-Aug;32(7):459-61. Available at: http://stfm.org/fmhub/fm2000/julyaug00/julyaugOBT.html Version 1.1, October 2007 5
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If students write in the official medical record, remember Health Care Financing Administration (HCFA) billing guidelines: Only the students past, family and social history (PFSH) and Review of Systems (ROS) can count for billing purposes. As the teaching physician, you must still write your own History of Present Illness, Physical Examination, Assessment and Plan for billing purposes.8 Students track their encounters using a handheld log. We will send you a report each year summarizing the types of patients the students saw in your office. Learning about office-based practice: Students may spend some time learning about office-based practice and how your office staff contributes to the care of patients.9 Conducting independent projects: Students may also spend time conducting independent projects (chart audits, develop patient education tools) that may benefit patient care in your office. Other examples are available.10 Teaching and learning Expectations about teaching time: Teaching time can be brief and between patients Brief teaching also at the beginning or end of the day or during the lunch hour, is appreciated if you have time Expectations on what to teach: Focus your teaching on 1-2 important points about a patient or disease One efficient teaching model: The Five-Step Microskills Model of Clinical Teaching (also known as the One-Minute Preceptor model). 11,12 Get a commitment Probe for understanding Teach general rules Reinforce what was done right Correct mistakes Encourage student self-learning by asking him/her to: look up information on the handheld computer or Internet research a topic as homework and give you a summary the next day do the case studies (diabetes, hypertension, asthma, hypercholesterolemia) that we offer them Directly observe the student performing at least one focused history and physical examination. The Plus/Delta method is useful tool for observation and giving feedback afterwards.13 Document your observation in their Clerkships passport Other successful teaching strategies reported in the literature are available.14,15

VII.

Chappelle KG, Blanchard SH,Ramirez- Williams MF, Fields SA. Off the charts: teaching students in compliance with HCFA guidelines. Fam Pract Manag. 2000 May;7(5):37-41. Available at: http://www.aafp.org/fpm/20000500/37offt.html 9 Moser S, Callaway P, Kellerman R. Involving the Office Staff in Teaching Medical Students. Family Medicine 2002:34(8):565-6. Available at: http://stfm.org/fmhub/fm2002/sept02/ftobtofm.pdf 10 Shreve R, Kaprielian VS. Independent Activities for Student Learning During Community-based Rotations Family Medicine 1998;30(6):408-9. Available at: http://stfm.org/teacher/1998/june/june.html (Scroll to the second-half of the webpage.) 11 Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching. J Am Board Fam Pract 1992 Jul-Aug;5(4):419-24 12 Neher JO, Stevens NG. The one-minute preceptor: shaping the teaching conversation. Family Medicine 2003 Jun;35(6):391-3. Available at: http://stfm.org/fmhub/fm2003/jun03/stevens.pdf 13 Qualters DM. Observing students in a clinical setting. Family Medicine 1999;31(7):461-2. Available at: http://stfm.org/teacher/1999/julaug/julaug.html 14 Epstein RM, Cole DR, Gawinski BA, Piotrowski-Lee S, Ruddy NB. How students learn from community-based preceptors. Arch Fam Med. 1998 Mar-Apr;7(2):149-54. http://archfami.ama-assn.org/cgi/reprint/7/2/149 15 Manyon A, Shipengrover J, McGuigan D, Haggerty M, James P, Danzo A. Defining differences in the instructional styles of community preceptors. Fam Med. 2003 Mar;35(3):181-6. http://stfm.org/fmhub/fm2003/mar03/mse.pdf Version 1.1, October 2007 6

VIII. Feedback Frequency of feedback: Strive to give feedback as often as possible after different patient encounters each day. Mid-clerkship feedback: Plan to have a brief session at mid-clerkship in which you give feedback and also allow the student to discuss how things are going from his/her perspective End of clerkship feedback: Plan also to give summative feedback at the end of the clerkship Characteristics of effective feedback16 , 17 behavior-specific timely balanced constructive Giving corrective feedback: Sandwich the corrective feedback with positive statements18: State one of the students strengths Then, discuss the area that needs improvement Conclude by stating another of the students strengths Other suggestions on giving constructive feedback are available 19 IX. Evaluation Online end of clerkship evaluation: We will contact you and ask you to complete an on-line evaluation on each student Rating items: please match the descriptor that best fits the students performance for that item Comments: please write thoughtful and specific comments that support how you have rated the student for the items in that category Please note that professionalism is an important item to evaluate in addition to the students knowledge and skills One strategy to write a meaningful evaluation: The GRADE strategy encourages you to collect and record information throughout the clerkship.20 Write your evaluation in a fair and objective manner that will stand up to future scrutiny in either an academic or legal setting If any questions or concerns about what to write, please contact the Clerkship Director We appreciate your completing this evaluation form in a timely manner so that we may issue students their grades on time Students also evaluate you as a preceptor and we will give you an annual report summarizing their evaluations of you.

Kaprelian VS, Gradison M. Effective use of feedback. Family Medicine 1998;30(6):406-7. Available at: http://stfm.org/teacher/1998/june/june.html 17 Ende J. Feedback in clinical medical education. JAMA 1983;250(6):777-81 18 LeBaron SWM, Jernick J. Evaluation as a dynamic process. Family Medicine 2000;32(1):13-4. Available at: http://stfm.org/teacher/2000/janOBT.html 19 Dobbie A, Tysinger JW. Evidence-based strategies that help office-based teachers give effective feedback. Family Medicine 2005;37(9);617-9. Available at: http://www.stfm.org/fmhub/fm2005/October/Alison617.pdf 20 Langlois JP, Thach S. Evaluation using the GRADE strategy. Family Medicine 2001;33(3):158-60. Available at: http://stfm.org/fmhub/fm2001/mar01/teacher.html Version 1.1, October 2007 7

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EVALUATION OF STUDENT PERFORMANCE FAMILY & COMMUNITY MEDICINE _______

NAME OF CLERKSHIP DATE OF ROTATION

Student:___________________________
LAST NAME , FIRST NAME

Amount of Contact with Student: ___________________

(E.G., # OF DAYS, # OF PATIENTS)

Evaluator: ____________________________Res/__Faculty/__Consensus ospital:__________________

LAST NAME, FIRST NAME (CHECK ONE) Consensus=multiple raters

COMMENTS: PLEASE COMMENT ON AREAS OF STRENGTH AND AREAS NEEDING IMPROVEMENT. CITE SPECIFIC ACTIONS/BEHAVIORS. Clinical Skills Knowledge Professionalism GRASP OF FAMILY MEDICINE

INSTRUCTIONS: Rate the students skill in each category using the descriptive labels as a guide. Darken bubbles with pen or pencil. CLINICAL SKILLS
HISTORY AND PHYSICAL Inaccurate data or major omissions Disorganized or unfocused, some omissions, lacks supporting detail Accurate, includes essential positives and negatives *Well organized, focused, comprehensive *Outstanding, discussion reflects thorough understanding of disease and patient situation

VERBAL PRESENTATIONS

Inaccurate, major omissions, rambling, inappropriate comments

Disorganized, unfocused, some omissions, gives irrelevant facts

Complete, includes all basic information, follows usual format

*Well organized, thorough, precise

*Concise, comprehensive presentation, appreciates subtleties

FUND OF KNOWLEDGE
GENERAL CONCEPTS Major deficiencies, little understanding of basic concepts Some deficiencies, incomplete understanding, difficulty applying basic concepts Okay understanding of basic concepts and diagnostic and treatment options *Expanded understanding of basics and options *Mastery of basics, thorough understanding of diagnostic and treatment options

PATIENT SPECIFIC

Lacks knowledge to understand common patient problems

Difficulty understanding problems or formulating treatment options

Understands basic differential diagnostic categories and treatment options

*Expanded understanding of differential diagnosis and treatment

*Assimilates and applies relevant literature

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Student: ________________________ LAST NAME, FIRST NAME Cannot interpret or PROBLEM synthesize data, no SOLVING/ prioritization, likely to SYNTHESIS miss major disorder

Some difficulty with interpretation of data and prioritization of issues

Forms adequate differential diagnosis with appropriate prioritization of issues

*Effectively integrates data, incorporates subtleties, thoughtful prioritization

*Understands complex issues and problem interactions

CLINICAL MANAGEMENT

Unreliable, fails to plan, misses changes in patient status, lacks follow-up

Erratic in planning and follow-up, slow to see changes in patient status

Adequate management plans/follow-up, adequate recognition of changes

* Thoughtful, detailed management plans, regular follow-up, quick to see changes

*Efficient and insightful management plans/ followup, suggests alternatives

INITIATIVE

Does not read or seek information, unreliable, inefficient time use

Requires reminders to seek more information, occasional inefficient time use

Reads expected amount, reliable follow though, effective time use

*Seeks additional reading, efficient, conscientious and helpful

*Highly motivated to expand knowledge and enhance productivity, goes out of way to help others

PROFESSIONAL JUDGMENT

Over estimates ability, unresponsive to criticism, acts on own without authority

Semi-responsive to criticism, fails to seek supervision when needed

Adequate decisionmaking, responsive to criticism, seeks help when needed

*Quality decisionmaking, seeks for and responds to feedback, clear view of limitations

* Exceptional decisionmaking, asked for advice by peers, effectively maximizes personal strengths

PROFESSIONALISM
WORKING RELATIONSHIPS Inappropriate, antagonistic, disruptive, arrogant Inflexible, inconsiderate, frequently looses composure Cooperative, adjusts to circumstances, team member *Flexible, supportive, develops good rapport with team *Poised, establishes tone of mutual respect with all team members

RELATIONSHIPS WITH PATIENTS

Avoids personal contact, tactless, inattentive to patients feelings

Occasionally insensitive or inattentive, superficial

Empathic, adequate communication, listens attentively, develops rapport

* Effective communication, perceived by the patient as capable

*Has patients full confidence, works exceptionally well with difficult patients

ATTENDANCE

Unexplained absence(s); frequently leaves prematurely or without checking with supervising residents

Frequently late for rounds, cannot be located during working hours; leaves before duties completed

Attends to assigned duties appropriately including patient care and required conferences

*Always available; punctual; attends supplemental conferences/activities

*Expends extra time and effort

HAVE YOU OBSERVED THIS STUDENT DOING A HISTORY AND/OR PHYSICAL? OVERALL RATING (SEE ATTACHED SCORING SYSTEM) Significant deficits Improvement Needs Acceptable Very Good

PLEASE DESCRIBE THE STUDENTS SUITABILITY AS A HOUSE OFFICER.

Good

Excellent

Outstanding

(have) or

(have not) reviewed this performance evaluation with the student. Signature: __________________________________________________________

Date: ____________

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