Goals and Objectives
During the third year of the MD Program curriculum, medical students at the University of Wisconsin School of Medicine and Public Health in Madison will complete an internal medicine rotation with the Department of Medicine. The clerkship includes the following overarching goals and learning activity objectives.
- Medical Knowledge
- Problem Solving and Clinical Skills/Patient Care
- Practice-Based Learning and Improvement
- Systems-Based Practice
- Interpersonal and Communication Skills
- Recognize the physiologic mechanisms that explain key findings in the history and physical exam
- Describe the etiologies, pathophysiology, clinical features, differential diagnosis, and related diagnostic testing and management of common inpatient medical conditions.
Problem Solving and Clinical Skills/Patient Care
- Complete a patient’s history and physical exam in a respectful, logical organized and thorough manner. When necessary, obtain supplemental historical information from collateral sources, such as significant others or previous physicians.
- Evaluate and prioritize problems with which a patient presents, appropriately synthesizing these into logical clinical syndromes.
- Formulate a differential diagnosis based on the findings from the history and physical examination and apply differential diagnosis to help guide diagnostic test ordering and sequencing.
- Formulate an initial therapeutic plan and explain the extent to which the therapeutic plan is based on pathophysiologic reasoning and scientific evidence of effectiveness.
Practice-Based Learning and Improvement
- Recognize when additional information is needed to care for the patient and demonstrate ongoing commitment to self-directed learning.
- Demonstrate ability to answer clinical questions using evidence-based medicine.
- Analyze gaps in knowledge and skills and see resources including assistance from colleagues to address gaps.
- Consider factors when performing diagnostic testing, including pretest probability, performance characteristics of tests (sensitivity, specificity, and likelihood ratios) and cost, risk and patient preferences and interpret these tests.
- Differentiate the role and contribution of each team member to the care of the patient, and call on interdisciplinary resources (case workers, nurses, physical therapists, etc.) to provide optimal and comprehensive care.
- Apply health systems-based thinking to address outcomes in patient care.
- Consider patient, physician, and system barriers (including cost) to successfully negotiate treatment plans and patient adherence; and understand strategies that may be used to overcome these barriers.
Interpersonal and Communication Skills
- Demonstrate appropriate listening and verbal skills to communicate empathy, elicit information regarding the patient’s preferences and provide basic information and an explanation of the diagnosis, prognosis and treatment plan.
- Perform as an effective member of the patient care team, incorporating skills in inter-professional communication and collaboration including giving and receiving feedback.
- Document and orally present new patient and follow up patient cases in a thorough and focused manner.
- Demonstrate a commitment to caring for all patients regardless of their medical diagnoses or social factors.
- Exhibit teamwork and respect toward all members of the health care team, as manifested by reliability, responsibility, honesty, helpfulness, selflessness, and initiative in working with the team.
- Demonstrate a positive attitude towards learning by showing intellectual curiosity, initiative, honesty, integrity, and dedication.
Learning Activity Objectives
- Inpatient Rotation
- Learning Reviews
- High Value Care Cost Analysis
- Required Topic Oriented Conferences/SIMPLE Cases
- Conduct an independent history and physical examination, adapting the scope and focus appropriately to the nature of the encounter (new vs. follow up) or complaint (complete vs. focused).
- Demonstrate empathy in patient interactions and commitment to caring for all patients regardless of background.
- Identify and prioritize problems with which a patient presents, appropriately synthesizing these into logical clinical syndromes.
- Formulate a differential diagnosis based on the findings from the history and physical demonstrating clinical reasoning.
- Apply differential diagnosis and probability based thinking to guide diagnostic test ordering, while considering test factors/characteristics, including their invasiveness, risks, benefits, limitations, and costs.
- Interpret the results of commonly used diagnostic tests.
- Formulate initial and daily therapeutic plan and explain the extent the plan is based on diagnostic reasoning and scientific evidence of effectiveness.
- Document the history, physical examination, and assessment and plan in a format appropriate to the clinical situation (e.g. admission note vs. progress note)
- Orally present a complete, well-organized summary of the patient’s history and physical examination findings, including an assessment and plan, modifying the presentation to fit the clinical situation.
- Discuss medical information in terms understandable to patients and families while avoiding medical jargon and demonstrating appropriate skills to demonstrate empathy.
- Demonstrate proficiency in specific physical exam and communication skills.
- Observe the communication of life altering news to patients and families.
- Identify members of the health care team and describe how they contribute to the patient’s care.
- Participate in patient care teams demonstrating inter-professional communication skills including giving and receiving feedback and respect to all members of the healthcare team.
- Demonstrate intellectual curiosity through identifying gaps in knowledge and skills and addressing these through independent information gathering and dissemination. (i.e. reading and discussing new information).
- Identify and reflect on an issue related to inter-professional teamwork in the care of a patient.
- Find current literature related to inter-professional teamwork and discuss its relevance to care of a patient.
- Identify and reflect on a systems-based practice issue that impacted the quality of patient care.
High Value Care Cost Analysis
- Analyze the use of laboratory tests for inpatients.
- Estimate a cost savings for more judicious use of tests.
- Develop a cost reduction strategy for future practice.
Required Topic Oriented Conferences/SIMPLE Cases
Acute Myocardial Infarction
- List the differential diagnosis of acute chest pain and narrow the differential based on specific physical exam findings.
- Define and discuss the pathogenesis, signs, and symptoms of the acute coronary syndromes.
- Describe cardiovascular risk factors and the primary and secondary prevention of ischemic heart disease.
- Develop an appropriate diagnostic and treatment plan—including recommended lifestyle modifications—for a patient presenting with acute coronary syndrome.
- Identify and translate auscultatory findings of the heart including rate, rhythm, S3/S4, and murmurs and interpret neck vein findings for jugular venous distension.
- List the major pathologic states which cause dyspnea and compare the differing etiologies and signs of left-sided vs. right-sided heart failure.
- Utilize the staging system for heart failure.
- Discuss the factors leading to symptomatic exacerbation of HF, including ischemia, arrhythmias, anemia, hypertension, thyroid disorders, non-compliance with medications and dietary restrictions, and use of nonsteroidal anti-inflammatory drugs.
- Recommend pharmacologic management of heart failure.
Hypoglycemia and DKA
- Diagnose type 2 diabetes mellitus using the four accepted criteria, as well as know the diagnostic criteria for impaired fasting glucose and impaired glucose tolerance and list ADA the targets for glycemic control.
- Recognize precipitants and presenting symptoms and signs of HHS and diabetic ketoacidosis (DKA), as well as discuss the pathophysiology for the abnormal laboratory values of each.
- Describe the basic management of diabetic ketoacidosis and nonketotic hyperglycemic states, including the similarities and differences in insulin therapy and fluid and electrolyte replacement.
- List symptoms and signs indicative of an acute/surgical abdomen.
- Approximate a likelihood ratio of the common causes of abdominal pain based on pain pattern, the quadrant the pain is located and abdominal exam findings.
- Generate a prioritized differential of the most important and likely causes of a patient’s abdominal pain and recognize specific history, physical exam, and laboratory findings that distinguish between the various conditions.
- Recommend a basic management plan for diverticulitis.
- Identify the common causes for and symptoms of upper and lower gastrointestinal blood loss, including recognizing the distinguishing features of each.
- Examine the role of contributing factors in gastrointestinal bleeding such as Helicobacter pylori infection, non-steroidal anti-inflammatory drugs, alcohol, coagulopathies, and chronic liver disease.
- Develop an appropriate evaluation and treatment plan for patients with a gastrointestinal bleed.
- Complete an appropriate history and physical exam for a patient with mildly abnormal liver function tests.
- Know when to order laboratory tests for evaluation of liver disease and be able to interpret the results.
- Differentiate common causes of liver disease from less common causes.
- Identify physical exam findings associated with cirrhosis.
- Advise a patient with liver disease about secondary prevention measures.
Delirium and Dementia
- Differentiate between delirium, dementia, and depression and identify the risk factors for developing these conditions.
- Recognize the symptoms and signs of the most common and most serious causes of altered mental status, including: prescription and non-prescription drugs, illicit substances and metabolic causes.
- Perform a thorough diagnostic evaluation of delirium and dementia.
- Manage the most common causes of delirium.
- Understand the meaning and utility of various components of the hemogram and identify morphologic changes on a peripheral smear to classify the anemia based on these indices/findings.
- Use information regarding the diagnostic utility of the various tests for iron deficiency when selecting a lab evaluation for iron deficiency.
- Identify key historical and physical exam findings in the anemic patient.
- Develop a further evaluation and management plan for a patient with anemia.
High Value Care
- Define High Value Care.
- Use validated decision support tools to increase accuracy and diagnostic efficiency.
- Estimate the harms and costs associated with common tests.
- Balance benefits with harms and costs of testing.
- List the common pneumonia pathogens in immunocompetent and immunocompromised hosts and describe radiographic findings.
- Identify bronchial breath sounds, rales (crackles), rhonchi, and wheezes, signs of pulmonary consolidation, and pleural effusion on physical exam.
- Recommend when to order diagnostic laboratory tests—including complete blood counts, sputum gram stain and culture, blood cultures, and arterial blood gases—how to interpret those tests, and how to recommend treatment based on these interpretations.
- Select an appropriate empiric antibiotic regimen for community-acquired, nosocomial, immunocompromised-host, and aspiration pneumonia, taking into account pertinent patient features.
- Discuss the Centers for Medicare and Medicaid Services (CMS) and Joint Commission’s quality measures for smoking cessation advice and vaccination against pneumonia and influenza in patients with pneumonia and other pulmonary disorders.
- Describe clinical presentation of sepsis syndromes.
- Develop appropriate treatment plan for patients with fever including the selection of an initial, empiric treatment regimen for patients with life threatening sepsis.
- Summarize CKD staging and list the most common causes of chronic kidney disease (CKD) and uremia and describe associated pathophysiology
- Tell about the pathophysiology of hyperkalemia, hypocalcemia, and hyperphosphatemia in the setting of chronic kidney disease.
- Appropriately recommend the use of ACE-Inhibitors and ARBs, calcium replacement and phosphate binders in the management of CKD.
Fluid and Electrolytes and AKI
- Compare the pathophysiology of major etiologies of acute renal failure including decreased renal perfusion (pre-renal), intrinsic renal disease, and acute renal obstruction (post renal).
- Calculate fractional excretion of sodium and apply it to distinguish between pre-renal and intrinsic renal disease.
- Develop appropriate initial management plan for acute renal failure including volume management, dietary recommendations, drug dosage alterations, electrolyte monitoring, and indications of dialysis.
- Interpret a urinalysis, including microscopic examination for casts, red blood cells, white blood cells, and crystals.
- Calculate the anion gap and generate a differential diagnosis for metabolic acidosis.
Lung, Breast, Colon and Rectal Cancer
- List the three most common causes of cancer death in U.S. adults.
- List the common risk factors for lung, colorectal and breast cancer.
- Describe the screening guidelines for lung, colorectal and breast cancer.
- Understand the difference between cancer therapies based on intent of treatment.
- Understand the difference between palliative chemotherapy and palliative care.
- Describe the common causes of tachypnea.
- List indications for thoracentesis and know laboratory findings of transudative and exudative effusions.
- List risk factors for the development of a deep vein thrombosis (DVT).
- Recognize the signs and symptoms of DVT and pulmonary embolism (PE).
- Generate a prioritized differential diagnosis of DVT/PE based on specific physical findings using pre-test probability tools.
- Develop an appropriate management plan for DVT/PE, including appropriate use and monitoring of heparin and warfarin.
- Know the approach to patients with possible rheumatologic disease.
- Know typical clinical and laboratory findings of rheumatoid arthritis, systemic lupus erythematosus (SLE), dermatomyositis, and systemic vasculitis.
- Compare and contrast the various causes of inflammatory polyarthritis.
Systems Based Practice
- Discuss why and how systems-based practice and systems thinking are important in providing comprehensive care.
- Describe the UW Systems Engineering Initiative for Patient Safety (SEIPS) Model of a work system.
- Use the SEPIS model to demonstrate systems thinking in addressing an undesired outcome, the processes involved and the contributing systems factors.