Applied Physical Diagnosis Content Guide

I. COURSE GOALS

1. To give students some experience working with REAL hospitalized patients. 2. To teach students how to interact with patients in a sensitive and respectful manner. 3. To give students some experience with presentation and discussion of actual cases. 4. To give students as NOVICE LEARNERS some experience seeking feedback from clinical faculty EXPERT LEARNERS.

II. COURSE OBJECTIVES

By the end of the course, students will be able to adequately demonstrate the following Content Objectives:

A. Knowledge Based Objectives:

1. Student will demonstrate that they understand the difference between Subjective, Objective, and Diagnosis terminology by correctly organizing their write-ups and oral presentations as follows:

a. Subjective symptoms will be reported only in the HPI and ROS section of the written note and oral presentation. b. Students will describe physical exam findings using Objective terminology in the Physical Exam portions of the written note and oral presentation. c. Diagnoses only be proposed in the Assessment section of the written note and oral presentation. Students will formulate possible Diagnoses by considering both subjective history and Objective Physical Exam findings.

B. Attitude based Objectives:

1. Students will demonstrate a willingness to learn via active participation in small group discussion. 2. Students will demonstrate openness to feedback and enthusiasm for learning by using feedback from faculty to improve performance. 3. Students will identify personal learning goals and seek feedback from faculty to address these goals. 4. Students will become more comfortable with process of receiving constructive feedback to improve their performance.

C. Skill based Objectives: 1. Students will elicit a full History on hospitalized patients. 2. Students will complete the full Adult Physical Exam (excluding breast, axillary, inguinal, genital, and rectal exams). 3. Students will document the History and Physical (H&P) on hospitalized patients with particular attention to appropriate organization of information. 4. Students will demonstrate the ability to differentiate subjective history from objective exam findings. 5. Students will be able to correctly document subjective information gathered in the history sections of the H&P note. 6. Students will be able to correctly document objective information gathered in objective physical exam sections of the H&P note. 7. Students will demonstrate the ability to identify and appropriately rank patient problems in a Problem List. 8. Students will be able to demonstrate the ability to formulate their own diagnostic opinions and document them in an appropriate Assessment section of the H&P. 9. Students will be able to appropriately demonstrate the ability to discuss Differential Diagnoses in their Assessments. 10. Students will be able to demonstrate the ability to formulate appropriate Plans 11. Student Assessments and Plans will be at the level appropriate for novice learners. 12. Students will be able to display the ability to deliver a concise and well organized 5 minute oral presentation.

To see how each of the Content Objectives are measured specifically measured: See Appendix 1. APD Student Performance Evaluation, and Appendix 2. Applied Physical Diagnosis : Examples and Explanations of Objectives on Student Performance Evaluation to see how

III. Course Overview: The course is designed in a small group format. Small group faculty-to-student ratios of 1:3 -1:6 allow the opportunity for small group discussion, peer feedback, & group bedside rounds to review interesting or abnormal physical exam findings. Each student will attend 4 small group sessions (2 in

Applied Physical Diagnosis Content Guide Applied Physical Diagnosis Content Guide

Fall and 2 in Spring). Students requiring remediation will be expected to attend additional remediation sessions as needed.

Small group size also allows faculty to observe student patient interactions at the bedside.

A. At each session: 1) Students interview and examine REAL hospitalized inpatient volunteers.

2) Each student will present a 5 minute oral presentation summarizing their patient’s case. Oral presentations and feedback will be in front of their small group so that all members can learn from each student’s attempt.

B. After Each Session: 1) Students submit written H&Ps by posting them on the Physicianship Blackboard site within the Applied Physical Diagnosis section. Instructions will be provided in the Addendum of the Student Orientation Materials.

2) Each students should submit their H&Ps using the following format: a) Each write up should include a header listing student name, date of interview with patient. b) Within each H&P ONLY USE PATIENT INITIALS not patient names to protect confidentiality. c) Save H&Ps in Microsoft Word (version 2007 or earlier) format to ensure all faculty will be able to open. d) Students should save their H&Ps with the following format for File Name:

StudentLastName_StudentFirstName_H&Pmonth.day.year for example Student Suzy Smith who has session #1 on Oct 1, 2012 would label her H&Pas follows: Smith_SuzyH&P10.1.12

3) Deadlines for students to post their H&Ps on the Blackboard: by 6 pm 2 days after the small group meets: Monday group H&Ps are due by 6pm Wednesday. Tuesday group H&Ps are due by 6pm Thursday. Wednesday group H&Ps are due by 6pm Friday. Friday group H&Ps are due by 6pm Sunday.

4) Faculty will complete Student Performance Evaluations via a rubric in Blackboard.

5) Faculty should provide narrative feedback to students using the comments sections on the Student Performance Evaluation rubric in Blackboard and by posting a revised copy of the student’s H&P to each student via Blackboard. Instructions regarding how to Post Narrative Feedback on Blackboard is provided in the Addendum of the Faculty Orientation Materials.

6) Deadlines for faculty to complete Student Performance Evaluations and to Provide each student with Narrative Feedback via Blackboard is by 6pm 10days after each small group session or 10 days after the student posts their H&P on Blackboard.

IV. Evaluation and Grading: 1. Student Performance Evaluation forms and faculty comments on completed H&Ps provide the opportunity for students to receive more individualized feedback on interviewing skills, written and oral communication skills, as well as professional behavior. This course is the first and only opportunity that these students have to interview and examine inpatients prior to starting their M3 clerkships.

2. Assessment of students’ performance is summative using the Applied Physical Diagnosis Student Performance Evaluation (APD SPE). Assessment of student’s performance is also formative using narrative feedback either written into the comments section of the APD SPE via the rubric embedded in Blackboard or by Faculty posting comments directly on the student’s H&PS and returning them to the students on the Blackboard platform.

3. Each Student Performance Evaluation Objective pertaining to a behavior that would be observed by the faculty member at the patient bedside will be assigned a score of either:

0=N/A - Unable to comment on behavior / There was no opportunity to observe student regarding this behavior 1=Unsatisfactory - Behavior absent or significant improvements needed. 2=Satisfactory - Behavior present and demonstrated in a well organized way / Little or no improvement is needed Any objective given a 0 will be excluded among the maximum possible points.

Applied Physical Diagnosis Content Guide Applied Physical Diagnosis Content Guide

4. All other Objectives pertaining to behaviors demonstrated through the student’s Oral Presentation or Written H&P will be assigned a score of :

1=Unsatisfactory - Behavior absent or significant improvements needed. 2=Satisfactory - Behavior present and demonstrated in a well organized way / Little or no improvement is needed

5. Students must achieve a minimum pass level with a score of 70% Satisfactory performance on the second H&P of each semester in order to pass the APD component of the Physicianship program. Students who do not achieve a minimum pass level for APD will not be allowed to progress to the M3 clerkships without completed required remediation exercises adequately as determined by the Content Leader.

V. Required Reading: 1. Textbook of Physical Diagnosis History and Examination, 6th Ed. Mark H. Swartz, W.B. Sanders, Philadelphia, 2010 Specific attention should be made to:  Section I: The Art of Interviewing  Chapter 6: Putting the History Together  Chapter 22: Putting the Examination Together  Chapter 28: The Clinical Record 2. Handout “Applied Physical Diagnosis: Examples and Explanation of Objectives on Student Performance Evaluation.” (matched with the course grading sheet objectives) written by Dr Kring 3. Handout: “The 5- Minute Presentation” by Jeff Wiese and modified by Art Evans, Cook County Hospital, 1999. 4. Handout: “A Lengthy Example” excerpted from: Paul L Fine The Wards: An Introduction to the Clinical Clerkships, Chapter 8: The Written Presentation. Little Brown & Co., Boston, 1994: 84-95. 5. Handouts: “Applied Physical Diagnosis: Excellent Examples of H&Ps” Parts 1, 2, &3. (these are former student write-ups with comments highlighting how the H&Ps met course objectives or with common tips for improvement.)

VI. S uggested Reading: 1. Maxwell Quick Pocket Reference: Robert W. Maxwell. Maxwell Publishing Co. (a small spiral bound guide- any edition will provide a basic and classic outline for H&Ps. Please note this guide does include a review of PMH diagnoses in the ROS section- which is not technically correct. ROS should be a Review of Systems for symptoms that a patient could recognize having experiencing. If a patient has an undiagnosed condition- they will deny it because they will not know. However if you are thorough and ask about the symptoms of a condition in the ROS, you will improve your ability to detect and diagnose.)

VII. Attendance: 1. Attendance is mandatory at all four sessions. 2. Students who are unable to attend a session due to a reasonable conflict must notify the Content Leader PRIOR to the missed session. Content Leader contact info: Dr. Gina Kring, [email protected], voicemail: 312-942-0469 ****If less than 24 hours before the scheduled session or if you have not yet received confirmation from Dr. Kring of the by the methods above, send an e-mail and page Dr. Kring at 312-942-6000 ID 9897. **** 3. Students with excused absences will be allowed to come to the hospital on their own time to make-up the missed history and physical exam; however, there is no way to make up the group interaction. 4. Small group faculty cannot excuse students for being absent. 5. Make up sessions are arranged outside of usual class times. See M2 schedule for dates and times blocked to allow for makeup/ remediation session. If additional remediation is needed, sessions will be arranged at the Content Leader’s discretion and availability.

VIII. Professional Conduct 1. Students are expected to conduct themselves in a professional manner at all times while interacting with patients,visitors, patient care staff, fellow students, and faculty. 2. Students are expected to participate in be attentive and participate in small group discussions. 3. No breast, axillary, inguinal, pelvic, genital, or rectal exams will be done during this course out of respect for patient volunteers.

Applied Physical Diagnosis Content Guide Applied Physical Diagnosis Content Guide

IX. Professional Dress Students are expected to dress appropriately, including wearing a white coat and ID badge, for these sessions. This shows respect for your patients as well as your colleagues. 6. Men should wear ties. 7. No gym shoes. No open toe shoes. Socks must be worn. 8. Women should wear pants or skirts that come to the knee. No see-through or shear clothing. 9. No capri pants, shorts. or jeans

X. Preparation/Equipment 1. Students are expected to be prepared for each small group experience by preparing an outline for gathering the H&P. 2. The Students are expected to come to each session with the necessary equipment which includes: o Watch with a second hand o Stethoscope o Sphygmomanometer* (blood pressure cuff) o Ophthalmoscope/Otoscope o Ear specula for otoscope* o Reflex hammer o Tuning forks (128 Hz and 512 Hz) o Penlight o Visual acuity card o Tongue blade* o Wooden cotton-tipped applicators*  *These items may be checked out from 7th Floor of the AcFac.  Items checked out must be returned by 12 noon the next day. Students must carry their belongings with them at all times. There is no secure place to leave belongings.

XI. WORKING WITH REAL PATIENT VOLUNTEERS 1. PATIENT CONFIDENTIALITY A. Students should not view patients’ charts, labs or computer information. B. To protect patient confidentiality, initials only (no names)should be used in write-ups. C. Remind students not to discuss patient cases in public areas of the hospital. D. Faculty model appropriate ways to discuss patient cases in halls (e.g. when rounding on unit)

2. PATIENT CARE A. This is purely an educational experience, and should in no way interfere with the treatment or evaluation of the patient.

B. IF ANY STAFF MEMBER NEEDS TO PERFORM A PROCEDURE, THERAPY, EVALUATION, PROVIDE COUNSELLING FOR THE PATIENT, ETC. THE STUDENT SHOULD STOP THE INTERVIEW OR PHYSICAL.

C. Short interruptions (10 min or less). If a doctor, nurse, or any other staff member needs to see a patient the student should introduce him or herself as an M2 student collecting an H&P for class. Ask if the interaction is expected to be short (10 minutes or less) e.g. checking vitals, giving medication, dressing change, or a physician rounding, you may ask both the staff member and the patient if you may observe. As long as both the patient and the staff member agree, you may observe and then resume your H&P with the patient’s permission. If the interruption lasts longer than 10 minutes see section D below. ** Step out of the room for any breathing treatments to avoid possible respiratory exposures.

D. Long Interruptions (over 10 minutes) or if pt refuses consent to stay: 1. Thank the patient 2. Give Certificate of Appreciation 3. Excuse yourself and immediately page your preceptor to be reassigned to another patient.

3. PATIENT CONSENT AND ORIENTATION: A. All patients assigned in the course gave informed consent to participate in this education experience. Patients are recruited and confirmed by verbal consent the morning before each small group session.

Applied Physical Diagnosis Content Guide Applied Physical Diagnosis Content Guide

1. Every effort is made to recruit patients who are alert, and oriented. However mental status can vary throughout the day. If you suspect that your patient may be demented or disoriented and there is no family member who also has agreed to give a history at the bedside, immediately stop the interview, and page your preceptor to be reassigned another patient.

4. PATIENT DROP OUT A. If the patient is unable or unwilling to complete the experience, for any reason, page your preceptor to be assigned to another patient.

B. Adjust Documentation of H&P if performed on more than patient volunteer. If a student needs to be reassigned to another patient after obtaining a history from the first patient, the student should not start with the HPI with the second patient. Rather the student should continue the history or exam where they left off. (i.e. PMH or ROS, or Physical Exam). The student should simply note in their write-up- at what point they had to change to a second patient and the preceptor will take this into consideration when grading the write-up. There will not be a penalty in grading as long as all components of H&P are completed between the 2 patients. Generally the Assessment and Plan should pertain to the patient from whom the HPI was obtained. The student should indicate at the beginning of the problems list and assessment section which patient they refer to.

Applied Physical Diagnosis Content Guide