M3 Core

Clerkship Objectives (Linked COM objectives and EPAs)

MED-1. Gather essential and accurate information about patients and their conditions through a complete or appropriately focused history, physical examination, and the use of laboratory data, imaging, and other tests, in the adult inpatient and outpatient settings.

MED-2. Develop an appropriately focused differential diagnosis and assessment plan based on patient information, evidence-based medicine, and clinical judgment.

MED-3. Document a clinical encounter in the written patient record in an effective and organized manner. Provide an appropriately prioritized and succinct oral presentation.

MED-4. Demonstrate interpersonal and communication skills with patients, families, and the interprofessional team. Apply these skills in a patient-centered way, incorporating systems-based practice (cost/benefit, quality, and patient advocacy) to benefit a diverse patient population.

MED-P-1. Demonstrate a commitment to life-long learning and continuous improvement of knowledge, skills, and attitudes. Make use of self-evaluation and feedback from others to manage uncertainty, adapt to change, and develop habits of continuous improvement.

MED-P-2. Demonstrate accountability to all patients and a commitment to carrying out professional responsibilities with integrity and compassion.

General Description

The Core Clerkship in Internal Medicine consists of an eight-week rotation during the junior year which is divided into two sections: six weeks of inpatient experience and two weeks of outpatient experience.

Structure

At the Memphis campus, the clerk will rotate through two of the following hospitals: the Regional Medical Center (ROH), the VA Medical Center (VAMC), the Methodist University Hospital (MUH), the Baptist Memorial Hospital - East (BMH-E). The educational effort of the Clerkship centers around the ward team (inpatient month). This will provide each student the opportunity to learn the basic principles of Internal Medicine, not only through direct patient contact, but also by observing and interacting with faculty and house staff. Each ward team will typically consist of an attending physician, a second or third-year resident, and two third-year medical students. The third-year clerk is a participating member of the ward team with responsibilities for patient care. The ward experience is enhanced by the faculty didactic series, Chief rounds and the Observed Structured Clinical Experience.

The outpatient rotation is consisting of two weeks of ambulatory rotation. The ambulatory rotation will be spent rotating through General Medicine and subspecialty clinics.

Course Materials

Recommended Textbook (You may choose from the following):

Internal Medicine Essentials for Students, Fifth Edition
Harrison’s Principles of Internal Medicine, 20^th Edition
Andreoli and Carpenter’s Cecil Essentials of Medicine, 10^th Edition
Cecil’s Textbook of Medicine, 26^th Edition

Curriculum

CDIM/SGIM Curriculum

The Medicine clerkship follows the version 3.0 of the CDIM/SGIM Core Medicine Clerkship Curriculum Guide: A Resource for Teachers and Learners. The guide is a cooperative project of the Clerkship Directors in Internal Medicine (CDIM) and the Society of General Internal Medicine (SGIM) and was originally created in 1995 under a contract with the Division of Medicine of the Health Resources and Services Administration’s Bureau of Health Professions.

Students should review the curriculum to understand the goals of this clerkship.

https://www.im.org/resources/ume-gme-program-resources/curriculum/cdim-curriculum

https://www.amjmed.com/article/S0002-9343(08)00755-9/fulltext

General Responsibilities

Inpatient
I. Conduct a Patient Interview
II. Perform a Physical Examination
III. Written and Verbal Communication
IV. Diagnostic Decision Making (develop a problem-oriented method of patient evaluation)

Students should carry 4-5 patients each day. Daily responsibilities include attending morning checkout and morning report, pre-rounding on patients, writing H&Ps on the patients you admit, writing daily progress notes on each patient, attending daily rounds and presenting your patients, following up patients, and create a differential and management plan yourself.

Observed H&P (EPA)

Students are required one full H&P or 4 different portions of H&P’s during the rotation to be observed performing to. Evals can be done in clinics as well as inpatient. Residents/faculty/outpatient preceptors can complete the task. The H&P form should be turned into the clerkship coordinator by the end of the Clerkship rotation.

Outpatient

The outpatient portion of the clerkship is designed to provide students with a broad view of outpatient (General Internal Medicine) and subspecialty medicine opportunities including sub-specialty clinics. Students will attend clinics five days per week with an outpatient preceptor. To get the most out of this experience, students should be proactive in trying to see patients on their own when permitted. Students are required to have each outpatient preceptor sign their ambulatory patient form per 1/2 day clinic during the 2-wk rotation.

Grading

Distribution

Component	Percent of Final Grade
Inpatient Rotation Evaluation (4-wk + 2-wk)	66.66% (2/3)
Shelf Exam	33.33% (1/3)
Outpatient (Ambulatory) Rotation	Pass/Fail

Grading Scale

The following scale will be used to assign final grades for the clerkship. Grades will not be rounded.

A: 89.5-100
B: 78.5-89.49
C: 67.5-78.49
F: 67.49 or lower

The standard deviation for final grades is historically very small. Therefore, a difference as small as 0.2 points is significant and will not be adjusted upwards.

Inpatient Rotation

This grade is determined by your inpatient attending(s) and supervising resident(s) with input from your interns based on patient workups, daily progress notes, participation in rounds, presentations, etc. The evaluation will be based on EPAs (Entrustable Professional Activities) and accounts for 2/3 of the final clerkship grade (66%) and completed on eMedley.

Student Core Clerkship Inpatient Evaluation

To give you an idea of how you are performing, your attending physician(s) and resident will provide written mid-month evaluation feedback halfway through your inpatient month. If the faculty fails to provide this feedback, the student is expected to ask the attending and the resident for the current evaluation. This form should be turned into the clerkship coordinator at the end of the second week of the inpatient rotation unless otherwise stated during orientation.

Outpatient Rotation

Students are required to turn in the patient card form for each half day activity during the two-week rotation. There is no evaluation form for ambulatory. Faculty or Residents do not evaluate students during their ambulatory rotation.

Comments from the outpatient/subspecialty faculty with input from the residents, and private preceptors during the outpatient rotation may be included in the inpatient pediatric evaluation that will be sent to Academic Affairs for inclusion in the MSPE.

The ambulatory rotation is either pass/fail and is contingent upon the return of the patient cards (signed by an attending/preceptors or resident/fellow). The student needs to bring the Patient Cards form to the Clerkship Coordinator on the last Friday of the rotation.

Shelf Exam

At the end of the clerkship, students will take the National Board of Medical Examiners (NBME) Medicine Shelf Exam as the written exam. This score accounts for 33% of the final clerkship grade. The minimum passing score is the 5th percentile adjusted for the quarter of the year. The minimum score to be eligible to receive an “A” for the clerkship is the 50th percentile adjusted for the quarter of the year. All clerkships will use the same cutoffs:

5%ile to pass the shelf
50%ile to be eligible for an A in the course
75%ile to convert the raw shelf score to 89.5

You can view a table of these percentile scores by quarter.

The retake of exams in clerkships taken in Blocks 5 through 10 must be completed by the first day of class in January. For those clerkships taken after Block 11 of the M3 year, the retake must be completed no later than the end of Block 8 prior to the year of graduation. Under special circumstances, a student may be able to retake the Shelf exam other than at the regularly scheduled time, and if so, 4 weeks’ notice must be given.

Failure to be re-examined will result in a failing grade for the rotation. The original test score will be averaged into the final overall grade. Failure of the re-exam or failure of any portion of the clerkship requires that the entire rotation be repeated.

Retaking exams

Important Notes on Grading

The Clerkship Director retains the right to discuss with the attending physicians any serious infraction, professionalism issues, extenuating circumstances, or positive behavior not previously known to the attendings and may advise the attendings to alter the student’s grade accordingly.

All portions of the IM clerkship including clinics and exams must be completed and passed within one (1) year of starting the medicine clerkship or by September of the senior year, whichever comes first. Failure of the first shelf exam, or any segment of the clerkship, negates the ability to receive an “A” as a final grade no matter in what the ultimate grade average results.

Students are required to turn in all assignments and documentation with appropriate signatures (clinic logs, observed H&P card, clinical skills rubrics, time logs and case logs) by the last day of the rotation. Students failing to complete assignments by the last day of the rotation will be notified in email of the missing assignments. If assignments (including time logs and case logs) are not completed by 4 weeks after the end of the clerkship, this will result in a drop of 1 letter grade for the final clerkship grade due to professionalism. Additionally, the Dean of Student Affairs will be notified. If all assignments are not completed by 8 weeks after the end of the clerkship, this will result in a failing grade for the clerkship and the full clerkship must be repeated.

Course Evaluations

Each student is strongly encouraged to complete a course evaluation at the conclusion of the clerkship (link will be emailed).

Helpful Links for Grading

Accommodations

Any student who feels he/she may need an accommodation based on the impact of a disability should contact Disability Services to self-disclose and officially request accommodations. All requests for accommodations must be submitted with supporting documentation and the Disability Services Self-Disclosure and Accommodation Request Forms. Although students may register for services at any time, please attempt to make arrangements within the first week of the clerkship as it does take time to process the request and review documentation. For additional information, contact academic success at tlc@uthsc.edu.

Any special testing accommodations need to be arranged at the beginning of the rotation, otherwise it may not be possible to honor requests (i.e. testing in the office, etc.)

Professionalism

In contrast to the first two years of medical school where much of a student’s grade is based on objective criteria obtained through written testing, the second two years base much of the grade on subjective clinical evaluation. Perusal of the evaluation form reveals that a portion of the grade is based on evaluation of professional and personal attributes. Physicians-in-training must possess certain necessary attitudes and interpersonal skills. Some of these are inherent, but much can be cultivated particularly in an environment filled with the appropriate role models. The administration of the University of Tennessee feels strongly about this and has published guidelines for Professional Behavior and Conduct reproduced here:

“The Clerkship Director retains the right to discuss with the attending physicians any serious infraction, extenuating circumstances, or positive behavior not previously known to the attendings and may advise the attendings to alter the student’s grade accordingly.”

Computer and Internet Use Guidelines

It has become standard that all large corporations monitor the computer use in their businesses. Methodist Universal Hospital, of which Le Bonheur is a part, BMH, ROH (formerly The MED), and VAMC are no exceptions. Students can be identified surfing inappropriate websites which will result in dismissal from medical school.

Students are expected to have completed the requested training and to have obtained access to the electronic medical record at the different hospitals prior to the beginning of the rotation. Please inform the clerkship coordinator on the first day of the rotation if you have not accomplished this.

For Cerner access (MUH) call IT helpdesk 901-516-0000 #2

For CPRS access (VA) contact: VHAMEM TRAINEE ONBOARDING vhatraineeonboarding@va.gov or call Ms. Carolean Bolden 901-523-8990 X 5020 or Ms. Louvisia Conley Louvisia.Conley@va.gov 901-577-3902

For EPIC access (BMH) call Ms. Laura Martin/GME (901)226-1350 or Laura.Martin@BMHCC.org

For Cerner Millennium access (ROH & Medplex) call ROH IT Help Desk (901)545-7480

Serious infraction of any of the above professional behaviors will result in automatic failure of the rotation no matter what the subjective evaluation or written final grades.

Conferences - Teaching Experience

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Assignments

Student Assignments

Typically, two third-year students are assigned to each ward team at the following hospitals: Regional One Health (four teams), the VA Medical Center (three teams), Methodist University Hospital (three teams), and BMH–East (two teams). All of the hospitals in Memphis vary in the overnight call schedule and have some form of a “night float” team system. On a “long call” day, the team typically takes admissions for 12 hours but on weekends the call schedule varies. At MUH, teams take 24-hour call on weekends, for example. You should take call with your team and follow the instructions and requirements laid out by your attending.

Clerks can expect to “work up” one to two new patients per call and to follow a maximum of five patients at any given time. You will occasionally go into call with five patients, but if a particularly interesting patient is admitted, you may be expected to work up and follow this new patient. In this case, the intern and resident alone can follow one of your patients. Student work hours are well defined in our student workload policy which is referenced below.

Clinical Skills Assessments (Rubrics)

Students will complete a clinical skills rubric for the following IM competencies: 1) ECG interpretation; 2) Abdominal Exam. The rubrics may be completed either during inpatient or ambulatory rotation. Student must be directly observed by a faculty member or supervising resident (PGY 2-4) for each skill. Students will have 2 attempts for each skill assessment and must achieve a rating of “able to perform independently” per rubric to pass this assignment.

This is a pass/fail assignment that must be completed and turned in to the clerkship coordinator prior to the end of the clerkship. It is the student’s responsibility to alert the attending or supervising resident to the need for this assessment, and to ensure that the skills assessment is completed prior to the end of the clerkship.

Observed History and Physical

Students are required four times during the rotation to be observed performing some or all of an H&P. Evals can be done in clinics as well as inpatient. Residents/faculty/outpatient preceptors can complete the task. The H&P form should be turned into the clerkship coordinator by the end of the Clerkship rotation.

*For Memphis location, this is in your Memphis Clerkship Packet.

Case Logs and Time Logs

Students are required to complete a log of their patient encounters (for a total of 22 Diagnoses). The log must include, but is not limited to, patients with the diagnoses listed in the Required Patient Encounter list. In order to ensure that you are seeing a breadth of patients, we require documentation of 22 competencies located on eMedley. You should be a participant in the patient’s care, not an observer. If you do not see a patient with a particular diagnosis, you should inform the Clerkship Director before the end of the Clerkship.

One patient may be used to fulfill multiple diagnoses below if appropriate. The log must be completed in a timely fashion as any deficits must be corrected during the clerkship in order to complete the rotation. Patient encounters can be logged by accessing the Student Information System, opening Clerkship Tracking from the list then choosing the Diagnoses/Procedure tab. The clerkship director will review your log and duty hours’ weekly.

Hours will be limited to 80 hours per week averaged over a four-week period, inclusive of all in-house call and patient care activities. Continuous on-site duty, including in-house call, will not exceed 30 consecutive hours. Students may remain on duty additional hours to participate in transferring care of patients, conducting outpatient clinics, maintaining continuity of medical and surgical care, and attending required didactic activities. Students will be provided with one day in seven free from all educational and clinical responsibilities, averaged over the rotation, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, didactic, and administrative activities. Students should be provided with a 10-hour period after in-house call during which they are free from all patient care activities.

Log your hours on eMedley. These will be checked multiple times throughout the clerkship by the coordinator and you will be emailed if you are behind. All hours must be logged by the end of the day on the last day of the rotation (shelf exam day).

Ambulatory Patient Cards/Forms

Students are required to turn in a patient cards form for each ½ day clinical activity during the two-week outpatient rotation. Students who are on ambulatory rotation are required to attend the noon Ambulatory rounds. They are generally every Thursday 12:00– 1:00 pm at the North Auditorium, Coleman Building.

*For Memphis location, these are in your Memphis Clerkship Packet.

Miscellaneous Information

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Policies

Attendance

Dress codes/Scrubs

UTHSC Dress Code

Grading Policies

Inclement Weather Policy

The administration at UTHSC decides when the campus is closed due to inclement weather. Closure indicates that classes and scheduled meetings are canceled. In the event that the school is closed, faculty and students with clinical responsibilities are professionally obligated to provide that care even during inclement weather. Students on clinical services are expected to continue to provide care for their patients, provided traveling would not place the student at serious risk of injury. Students should consult with their resident and physician supervisors to determine the risks/benefits involving travel during these periods. Students who are unable to travel to the rotation sites should contact preceptors as soon as possible to advise them of the individual situation and whether the student could reach the site later in the day.

Since weather conditions will vary across the state, clerkship students on the three campuses will follow the schedules dictated by those campuses.

Mistreatment

If you feel you are being mistreated, we encourage you to talk to the person who is mistreating you first. On the inpatient rotation, you should discuss any issues with your supervising resident followed by the attending. If the issue is still not resolved, then you should contact the clerkship director. On the outpatient rotation, you should discuss any issues with the supervising physician then the clerkship director. If the issue is sensitive or you feel uncomfortable addressing the issue with the clerkship director, then discuss the issue with the Dean of Student Affairs. Please refer to the policies below for further details:

Needle Stick Injury

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