Academic Year 2017-2018

INTMD 7510-7550: CORE Sub- in Internal Medicine

Approved: June 5, 2017

Contact Information Name Position Phone/Pager email Katie Lappé, MD Director Via Smartweb [email protected] Carol Stevens Coordinator 801-585-7716 [email protected]

Core Sub-Internship Information Brief Description of Sub-Internship This course is a 4-week clinical experience in a hospital setting. The student will act as a sub-intern with a commensurate level of responsibility that includes a patient load of at least 2/3 that of current interns, overnight and/or after hours cross- cover responsibilities, and duty hours restrictions consistent with the UUSOM Standard Practice for Clinical and Educational Work Expectations and the 2017 ACGME Common Program Requirements section VI.F. Clinical Experience and Education for residents. Clinical Course Goals As a result of completing the Internal Medicine Core Sub-Internship, students will have demonstrated the ability to perform each of the following for hospitalized patients presenting with new and follow-up core chief complaints/diagnoses relevant to the course: 1. Patient Interviewing & Physical Examination: Perform an accurate complete or focused patient interview and physical exam in a prioritized, organized manner without supervision, with respect for the patient, and tailored to the clinical situation and specific patient encounter. Integrate the scientific foundations of medicine with clinical reasoning skills to guide information gathering (EPA 1) 2. Clinical Reasoning: Dynamically Integrate patient data to formulate an assessment, develop a working diagnosis and prioritized list of alternate potential diagnoses. Avoid common cognitive errors of clinical reasoning (EPA 2). 3. Diagnostic Testing: Select and interpret common diagnostic and screening tests using evidence-based and cost- effective principles (EPA 3). 4. Orders & Prescriptions: Enter safe orders and prescriptions for patients in the inpatient setting (EPA 4). 5. Documentation: Enters accurate, focused, and context-specific documentation of a clinical encounter in either written or electronic formats (EPA 5). 6. Presentation: Concisely and accurately present a summary of the clinical encounter and synthesis of clinical reasoning to the health care team (including patients and families) to achieve a shared understanding of the patient’s current condition (EPA 6). 7. EBM: Identify key clinical questions, locate and appraise information resources, and assess applicability to individual patients (EPA 7). 8. Handoffs: Deliver and receive effective and efficient handover communication during transitions of responsibility from one health care team or practitioner to another (EPA 8). 9. Teamwork: Apply understanding of roles, responsibilities, and contributions of individual team members to contribute to safe, timely, effective, efficient, and equitable patient care (EPA 9). 10. Communication: Communicate effectively with patients and patient’s family members utilizing lay terms. Provide concise daily updates for patients and families. Communicate effectively with physician and non-physician members of the team. Demonstrate an understanding of the importance of communicating with the patient’s PCP at time of discharge. 11. Coordination of Care: Appropriately utilize consultants (request consultation after identifying a specific question(s) to be addressed and discuss a consultant’s recommendations with the medical team). Demonstrate proficiency in coordinating a comprehensive and longitudinal patient care plan. Communicate plan with outpatient health care provider, arranging follow-up when necessary.

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12. Critical Care: Recognize deteriorating patients who require urgent or emergent care, recommend initial evaluation and management, and seek help in escalating care for patients with (EPA 10):  chest pain  mental status changes  shortness of breath and hypoxemia  fever  hypotension and hypertension  tachycardia and arrhythmias (e.g., SVT, Afib, heart block)  oliguria, anuria, urinary retention  electrolyte abnormalities (e.g., hyponatremia, hyperkalemia)  hypoglycemia and hyperglycemia 13. Consent: Obtain informed consent for core interventions, tests, or procedures (EPA 11). 14. Patient Safety & Quality Improvement: Identify and admit potential and actual errors and use system mechanisms for error reporting (EPA 13).

Clinical Course Format & Schedule

Attendance Expectations The UUSOM has created a rigorous advanced clinical curriculum that requires all medical students to successfully complete four-week experiences in each of Advanced Internal Medicine, a Core Sub-Internship, and a Critical Care Clerkship. Recognizing that most students will complete all three of these experiences during the fourth year of their curriculum that coincides with the USMLE 2 CK and CS examinations and the application and interview period, the Phase IV Subcommittee has established attendance expectations for these courses that balance the need for physical presence during the courses with flexibility to accommodate exam and interview obligations. The attendance expectations for these courses are therefore that:

Students should expect to fully participate in course activities as described in each course syllabus and consistent with Clinical and Educational Work expectations.

Each student is allowed a maximum of three additional days away from the course to participate in residency program interviews and/or sit for USMLE Step 2 Clinical Knowledge and Clinical Skills testing. The Course Director and Clinical Site Director must approve these absences at least 48 hours in advance. Before requesting use of these additional days away from the course, students should first use the clinical and educational work free days outlined in the Clinical and Educational Work expectations for interviews and examinations.

Regardless of absence, students remain responsible for required assignments, content mastery, and completion of required clinical experiences.

Clinical and Educational Work Expectations The University of Utah School of Medicine is committed to ensuring that its medical students have optimal opportunities for learning in the clinical curriculum balanced by the need for student physicians to be appropriately rested and fit to participate safely in patient care activities. To this end, the clinical and educational work expectations of Phase III and IV medical students are aligned with the 2017 ACGME Common Program Requirements section VI.F. Clinical Experience and Education for residents: https://www.acgmecommon.org/2017_requirements.

Highlighted Details of Clinical and Educational Work Hours for Phase III & IV Medical Students  Clinical and Educational Work refers to in-house clinical and educational activities and specifically excludes independent study time necessary for success in the clinical curriculum.  Clinical and Educational Work hours are limited to 80 hours per week averaged over a 4-week period.  Students must be scheduled one day free of clinical and educational work every week averaged over a 4-week period.  Maximum continuous clinical and educational work periods should not exceed 24 hours plus a maximum of 4-hours for care transition.  Students must have at least 14 hours free of clinical and educational work after 24 hours of in-house call.  The minimum interval between scheduled clinical work and educational periods should be 8 hours.

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 The minimum interval between in-house 24-hour call periods is every third night averaged over a 4-week period. Timeline

 28 days in duration  Averaged 1 day off per week (3 days off per rotation with the fourth weekend off prior to the start of the next rotation)  Each student is allowed a maximum of three additional days away from the course to participate in residency program interviews and/or sit for USMLE Step 2 Clinical Knowledge and Clinical Skills testing  ACGME work hours should apply as if the student were a resident (need overnight) 80 hr/wk; 1 day/wk off

Sub-interns are expected to receive daily sign out on their patients by 6:30 am. The admitting cycle varies slightly at each clinical site (U, VA, IMC), however, in general, sub-interns should expect to admit patients until 6:00 pm 2-3 days out of every 4-day call cycle. Inpatient Internal Medicine wards are busy, and you should expect to work approximately 12 hour days, 6 days a week. Sub-interns should review their site-specific admitting schedule and arrange days off with their supervising resident on the first day of the rotation. Sub-interns will take an average of 1 day off per week (3 days off during the course of the rotation with the fourth weekend off). Sub-interns are expected to participate in transitions of care and should be supervised by the senior resident in the sign out process in the afternoon/evening.

Excused Absences for AY 2017-2018

Longitudinal Mentoring for Residency – excused from 1:00 – 5:00 PM - Session 3 – June 28, 2017 (Week 3) - Session 4 – August 16, 2017 (Week 2) - Session 5 – September 6, 2017 (Week 1) - Session 6 – October 11, 2017 (Week 2) - Session 7 – January 10, 2018 (Week 1) - Session 8 – February 7, 2018 (Week 1)

Match Day – March 16, 2018 (entire day excused) Schedule The complete calendar and list of objectives for each event/activity can be found on the clerkship’s Canvas site. Canvas can be accessed at: https://utah.instructure.com/

Conference Schedule Students are expected to present one AM report at their clinical site during their rotation. In addition, students are expected to attend all AM reports and noon conferences at their clinical site as well as Grand Rounds (as able, can also watch live stream at the VA and IMC by using the following link: http://medicine.utah.edu/internalmedicine/grand_rounds.php)

Sample Conference Schedule for VA Monday Tuesday Wednesday Thursday Friday AM Report – AM Report – Grand Rounds– AM Report – 8:00-8:45 8:00-8:45 7:45-8:45 8:00-8:45

Noon Conference - Noon Conference - Noon Conference - 12:30-1:15 12:30-1:15 12:30-1:15

Sample Conference Schedule for UU and IMC Monday Tuesday Wednesday Thursday Friday Grand Rounds– 7:45-8:45

Housestaff Case Noon Conference - Noon Conference - Noon Conference - Housestaff Case Report – 12:30-1:15 12:30-1:15 12:30-1:15 Report – 12:30-1:15 12:30-1:15

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Grand Rounds is located in HSEB 1750.

AM Report and Noon Conference teaching sessions occur in the same location at each hospital.

University – Cartwright Conference Room (4th floor SOM between B and C elevators) VA – Tsagaris Conference Room (2nd floor at end of the “B” patient hall) IMC – Doty Education Conference Room Classroom 3, 4 and 5 Educational and Instructional Modalities 90% clinical work 5% clinical didactics 5% lectures Role of the Student in this Clinical Course Sub-intern students on the Internal Medicine service are expected to follow a minimum of 4 patients at a time (or 2/3 the number of patients followed by the intern). For each patient the student should perform all of the typical intern responsibilities including: obtaining an admission history and physical examination, performing daily rounds, retrieving clinical information from the electronic medical record and other sources, presenting the patient during team rounds, finalizing treatment plans with the supervising resident or preceptor and patient, entering all documentation in the medical record, writing all orders and prescriptions, communicating with consultants and health care team members, maintaining the physician patient relationship, and navigating the health care system. In addition, sub-interns are expected to cross cover and round on intern patients (in addition to their own) on intern days off. This is in order to measure the sub-interns efficiency and ability to function at the level of an intern. Core Chief Complaints, Core Diagnoses & Clinical Encounter Criteria During the Internal Medicine Sub-internship, students are expected to experience and participate in a variety of clinical encounters with patients. Students are required to log 25 inpatient encounters during their 4-week rotation. Students are required to log their encounters in the Case Log (found on Canvas) over the course of the clerkship. Each student remains responsible for completion of the patient log; any student with concerns that he/she is in jeopardy of not encountering the requisite number of encounters for a particular profile, setting, core chief complaint, or core diagnoses should notify the clerkship director (Katie Lappé, [email protected]) by the end of the second week of the rotation to ensure that these experiences can be arranged. Core Level of Student Number Chief Complaint, Diagnosis, Visit Type, Allowed Clinical Settings Alt Responsibility Required Procedure Minimum Number of Patients Inpatient DPC; TMPC 25 *Levels of Student Responsibility: Provide Direct Patient Care (DPC), Participate as a Team Member for Patient Care (TMPC), Observe Patient Care (OPC) **Where indicated with a  online cases, textbook reading, and or didactic experiences are allowed as alternatives to clinical experiences.

Recommended Textbook(s)/Readings  Kasper, et al, Harrison’s Principles of Internal Medicine 18th Ed., McGraw-Hill, 2012. (available on library website)  Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. 2010.  Primer to the Internal Medicine Sub-internship (found on Canvas)

Assessment & Grading Formative Clinical Performance Assessment All Phase IV Core Sub-Internships employ a common formative feedback form that includes both a Student Self-Assessment and Faculty/Resident Evaluation of Student section (Formative Clerkship Feedback Form). This self-assessment and feedback is intended to be formative in nature and will not be used in the calculation of Preceptor Evaluation data for final grade determination. An attending should give you verbal feedback and fill out the form.

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Students will be required to complete the Formative feedback form by the second and fourth Mondays of the four-week block. Students will be responsible for timely completion and submission of the data to Canvas. Students with formative feedback suggesting need for remediation should meet with the Dr. Lappé to develop a remediation strategy.

Preceptor Evaluations All Phase IV Core Sub-Internship Courses employ a common preceptor evaluation form that instructs evaluators to select performance based behaviors along multiple dimensions that best represent the student’s highest sustained performance during the preceptor’s period of observation.

Assessments Competency/Core Weight towards Assessment Name Entrustable Professional Date for 2017 Final Grade Activity Assessed Assignments Conference Attendance (AM Report and P/F PCRS 5 Noon Conference) AM Report Presentation P/F PCRS 1 (EPA 1a, 1b, 2, 3, 4, By last Thursday of rotation 6) Patient Log P/F PCRS 5 By last Thursday of rotation Formative Feedback (2) P/F PCRS 3 2nd and 4th Monday of the rotation Global Rating Forms Preceptor Evaluations 100% PCRS 1 (EPA 1a, 1b, 2, 3, 5, 6, 9) Quizzes None Final Examinations None

Grading System & Remediation Each assessment score from the table above is converted to a score between 0-4 where 2.0 represents a passing score and 4.0 is the maximum score before a final numerical score is calculated. Final numerical scores are rounded to 1 decimal point (e.g. 3.49 = 3.5).

Students will receive a final letter grade of HONORS (H), HIGH PASS (HP), PASS (P), or FAIL (F).

HONORS: A final numerical score of greater than or equal to 2.6 in addition to passing the Must Pass elements of the Sub-Internship.

HIGH PASS: A final numerical score of 2.4 to 2.5 in addition to passing the Must Pass elements of the Sub- Internship.

PASS: A final numerical score of greater than or equal to 2.0 and passing each Must Pass element of the Sub-Internship.

FAIL: A final score of less than 2.0 and/or failure of one or more Must Pass elements of the Sub-Internship.

A student who fails to achieve a passing score on the first attempt of any Must Pass element of the Sub-Internship may not obtain a Sub-Internship grade of HONORS.

Must Pass Elements of the Sub-Internship:

1. Preceptor Evaluations: Clinical performance assessed in the preceptor evaluation is a must pass elements of the Internal Medicine Sub-Internship. A student must achieve an average score of 2.0 or greater in each core performance domain in order to pass the Sub-Internship.

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2. Clinical Didactics and Noon Conference: You are expected to attend AM report and noon conference at your assigned clinical site (U, VA, or IMC). Students who miss >20% of these sessions will receive a grade of FAIL for this element.

Must Complete Elements of the Sub-Internship:

1. You are expected to present one morning report during your rotation. This should be arranged with the chief medical resident at your site. You are responsible for having the chief medical resident document completion of the AM report using the form found on Canvas assignments. Once signed, this should be uploaded to Canvas to receive credit. 2. Formative Feedback Forms: You are expected to submit two feedback forms during your clinical rotation as outlined above. 3. Patient Log: As outlined above, you are required to keep a patient log during this rotation. You need to have a minimum of 25 patient encounters during the 4 week block.

A student who fails to achieve a passing score for a must pass element on the first attempt and subsequently successfully remediates will receive a score of 2.0 regardless of the remediation score.

Any student who fails a Must Pass element of the Sub-Internship will receive and grade of FAIL for the course and be referred to the Promotions Committee.

Student Feedback Student feedback is an important aspect of curriculum quality improvement. Thus, students are required to complete all assigned feedback surveys specific to a course by the due date. For clinical courses in Phases 3-4 the required surveys are an end-of-course survey and individual surveys of clinical faculty. Surveys are administered online and student responses are anonymous.

Please refer to the resource section of the course canvas page for all Academic Year 2017-2018 student feedback survey due dates.

Standard Policies Please refer to the Student Handbook (on the Student Affair’s website) for these policies: Accommodations Addressing Sexual Misconduct Attendance policy Dress Code Examination and Grading Policies Grade or Score Appeal Professionalism, Roles & Responsibilities Mistreatment

Alternate Name and/or Personal Pronoun Class rosters are provided to the instructor with the student’s legal name as well as ‘Preferred’ first name (if previously entered by you in the Student Profile section of your CIS account). While CIS refers to this as merely a preference, we will honor you by referring to you with the name and pronoun that feels best for you in class, on papers, exams, group projects, etc. Please advise us of any name or pronoun changes (and please update CIS) so we can help create a learning environment in which you, your name, and your pronoun will be respected.

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Center for Disability & Access Services The University of Utah seeks to provide equal access to its programs, services and activities for people with disabilities. If you will need accommodations in the class, reasonable prior notice needs to be given to the Center for Disability and Access, 162 Olpin Union Building, 581-5020 (V/TDD). Staff of the Center for Disability and Access will work with you and the instructor to make arrangements for accommodations. All written information in this course can be made available in alternative format with prior notification to the Center for Disability and Access.

The Senior Director of the Academic Success Program, Dr. Steven Baumann (1C047B SOM Dean’s Office, 587-3671, or ([email protected] ), serves as the liaison between the School of Medicine and the Center for Disability and Access.

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