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Competency-Based Curriculum Resource for Preclerkship Education (using ACGME Structure):

Medical Knowledge

Lead Authors: Larrie Greenberg, MD and Rick E. Ricer, MD

**Workgroup Members**
Christine Matson, MD, Chair	Eastern Virginia Medical School
Scott A. Fields, MD	Oregon Health and Science University
Jeffrey Stearns, MD, Executive Committee Liaison	University of Wisconsin Milwaukee Clinical Campus
Eric Bass, MD	Johns Hopkins University
Thomas Defer, MD	Washington University
Allan Goroll, MD	Harvard University
Larrie Greenberg, MD	George Washington University
Mary Ann Kuzma, MD	Drexel University
Steve Miller, MD	Columbia University
William Raszka, MD	University of Vermont
Rick E. Ricer, MD	University of Cincinnati
John C. Rogers, MD, MPH	Baylor Medical College
William Wilson, MD	University of Virginia

Rationale

When entering core clerkships, students must be prepared to apply knowledge of pathology and pathophysiology to patients' clinical problems. Typically, basic science faculty members teach these concepts in disciplinary courses or in courses organized by organ systems. However, many concepts do not fit well into an organ system or discipline-specific teaching, but instead require a knowledge base that crosses several disciplines, areas, and systems. Students should understand the effect of diseases on the entire person, family units, communities, and the environment, as well as how the entire person, the family unit, communities, and environment affect the identified patient. Students ought to be able to differentiate among disease, illness, and health. They should understand processes that affect patients that are not usually considered "disease" (e.g., aging, pregnancy, violence, sexual dysfunction, and chronic pain.) Students must understand how lifestyle issues affect an individual's and a community's health, and may be the most important factor affecting health and disease other than genetics (e.g., substance abuse, obesity, nutrition, or exercise.) Students should understand how gender, race, culture, social economic status, and health beliefs affect the presentation and understanding of disease processes and, therefore, adherence issues. Many topics that are germane to this section are covered well in other competency sections and therefore are not repeated in this section.

Competency

Students must demonstrate understanding of established and evolving biomedical, clinical, and cognate (epidemiological and social-behavioral) sciences, and the application of this knowledge to patient care.

Goals

Before beginning clinical clerkships, students will be able to demonstrate:

An investigatory and analytical thinking approach to clinical situations.

Recognize that the chief complaint is the starting point for the focused history and physical examination.
Contrast the interview process of focusing on the chief complaint versus eliciting all of the patient's reasons for the visit at the beginning of the interview.
Describe possible effects on quality of information elicited by using a doctor-centered versus a patient-centered approach to the interview.
Seek and locate many resources useful for obtaining information, such as patients, their families and significant others, old records, attending physicians, the medical literature, electronic sources, group discussions, and conferences.
Proceed in an iterative fashion in the evaluation and management of the patient by performing the history and physical examination, prioritizing the differential diagnosis and workup, determining a diagnostic and management plan based on all of the findings, and explaining the plan in terms the patient can understand.
Describe the biopsychosocial approach to diagnosis and treatment of patients.

An understanding of the biomedical basis of disease and disease processes.

Describe the normal structure and function of the body and its organ systems.
Describe the molecular, biochemical, and cellular mechanisms for homeostasis.
List the various causes (genetics, developmental, metabolic, toxic, microbiologic, autoimmune, neoplastic, degenerative, traumatic, and functional) of diseases and the ways in which they operate on the body (pathogenesis).
Describe the pathology and pathophysiology of the body and its major organ systems that are seen in various diseases and conditions.
Describe and understand the scientific method in establishing the causation of disease and efficacy of traditional and nontraditional therapies.

Knowledge and application of strategies for effective learning and improvement.

Identify learning objectives for each course.
Demonstrate required knowledge base in each course.
Attend and participate in all required conferences.
Seek appropriate venues for the expansion of knowledge base.
Seek feedback on areas of knowledge base weakness.
Demonstrate acceptance of constructive feedback and efforts to improve.
Proactively identify and correct cognitive and behavioral weaknesses.
Develop a plan for lifelong learning.

Knowledge of development and changes across the lifespan.

Describe functional changes from newborn through the lifespan to the elderly.
List normal growth and development changes throughout the lifespan.
Explain why different age groups are vulnerable to different disease processes.
Differentiate normal aging from disease and dysfunction.
Describe a typical, healthy, active, productive elderly person.
Demonstrate how to obtain a basic prenatal history.
Demonstrate systemic examination of obstetric patients.
Demonstrate systemic examination of newborns.
Demonstrate systemic examination of infants and children.
Describe developmental and health issues in the clinical care of adolescents.
Demonstrate how to assess functional status.
List alternatives for the care of dysfunctional elderly.
Describe the stages of normal emotional and cognitive development.

An understanding of nutrition in health and disease.

Define the role of nutrition in disease prevention and health.
List the nutritional needs for growth and development from neonates to elderly.
Describe the optimal nutrition for people in different stages of the lifecycle.
Describe the function of vitamins, minerals, and supplements.
List the pros and cons of using supplements to prevent or treat disease.
List specific dietary changes needed to counter deviation from normal (e.g., high cholesterol, iron deficiency, or low potassium.)
Describe the nutritional requirements needed in acute and chronic conditions.
Define the prevalence and health risk of obesity across the lifecycle.
List the diseases associated with nutritional deficits.
Define the epidemiology, pathophysiology, symptoms, and physical findings of disease caused by nutritional deficits (e.g., rickets or scurvy.)
Define eating disorders, presentation of these problems, and treatment options.
Describe the benefits and risks of special diets.
Demonstrate how to obtain a nutritional history.
Demonstrate basic skills for giving patient education on nutritional topics and counseling for lifestyle changes.

An understanding of the science and management of pain.

Describe domains of pain: severity, location, referral, exacerbation, and remission.
Define pain by level of severity.
Describe how pain affects functional status and psychological well-being.
Describe how therapies help patients with acute and chronic pain.
Describe the dangers of under treating pain.
Describe the dangers of over treating pain.
List medications for adequate pain control.
Define the concept of dependence, tolerance, and adequate treatment.
List the problems associated with pain medications used on a long-term basis.
Demonstrate how to assess pain severity.

An understanding of the concept of chronic illness.

Define the concept of illness and disease.
Differentiate between acute and chronic illness.
List common chronic illnesses.
List the work up for common chronic illnesses.
Describe the physical changes and examination findings as diseases progress.
Describe the long-term outcomes of common chronic illnesses.
Describe treatments that prevent long-term complications of chronic illnesses.
Give examples of the patient's primary role in managing chronic diseases.

An understanding of the principles of environmental medicine.

Describe the influence of environmental agents on human health.
Describe concepts of exposure, dose, and susceptibility to environmental diseases.
Describe which occupations are at highest risk for specific injuries and illnesses.
List preventive strategies for occupational injuries and diseases.
Describe the presentations, clinical findings, and treatments of occupational injuries and diseases.
Describe the major information, clinical, and other resources available to help address individual, work place, and community health problems and concerns.
Demonstrate the ability to elicit an occupational and environmental history.

Comprehension of normal human sexual function and sexual dysfunction.

Describe normal sexual function and sexual dysfunction.
Describe sexual changes across the lifecycle.
List and describe presentations of sexual dysfunctions.
List the diseases associated with sexual dysfunction.
List the medications associated with sexual dysfunctions.
Describe the workup of sexual dysfunctions.
List the treatment modalities for specific sexual dysfunctions.
Describe the diversity of human sexual values, attitudes, beliefs, and behaviors.
Describe health issues related to sexual orientation.
Describe the impact of the sexual orientation of physicians on their relationships with their patients and colleagues.
Demonstrate nonjudgmental behavior toward patients with different values.
Demonstrate skill in taking a sexual, behavioral history in a sensitive manner, and define unique healthcare needs for gay and lesbian patients.
Demonstrate the ability to give patient education in a sensitive fashion and at the level of patient's understanding.

An understanding of the concept of prevention and preventive medicine.

Differentiate primary, secondary, and tertiary prevention.
List the most common causes of death for age groups across the lifecycle.
Outline preventive strategies across stages in the lifecycle.
List the US Preventive Services Task Force Guidelines for lifecycle age groups.
Differentiate preventive recommendations based on expert opinions from recommendations based on evidence-based studies.
Describe the principles of immunization.
List the recommended immunizations by age across the lifecycle.
Describe the concept of a risk factor.
Describe and list risk factors for preventable diseases.
Describe the concept of "at risk" populations.
Describe how preventive recommendations are altered by risk stratification.
Describe how the behavioral aspects of health habits may be modified.
Describe the physician's role in health promotion, patient education, community advocacy, and preventive medicine activities.
Describe the role of periodic preventive health assessment and routine preventive services.
Demonstrate how to conduct a periodic health exam and assessment of children and adults, including physical examination pertinent to screening.

Knowledge of substance use disorders and other addictions.

Define substance use, substance abuse, and addiction.
List the substance abuse disorders and other addictions.
List the risk factors for addictive disorders.
List the treatment options for addictive disorders.
Describe behavioral changes required for the treatment of addictive disorders.
Define an impaired physician.
Describe issues about substance abuse and addictions in health professionals.
Explain the legal responsibilities for reporting impaired physicians.
Demonstrate the elements of screening for addictive disorders.

An understanding of the concept of violence and neglect across the lifespan.

Differentiate abuse and neglect.
Describe the epidemiology of abuse, violence, and neglect across the lifespan.
Describe the cycle of escalating violence and violence across generations.
Describe the differing societal and cultural norms for attitudes regarding violence, acceptance of parental violence, and definition of family boundaries.
Describe the spectrum of child abuse and neglect, including legal aspects.
Describe the spectrum of domestic violence and neglect, including legal aspects.
Describe the spectrum of elder abuse and neglect, including legal aspects.
Describe the signs and symptoms of abuse and neglect.
Describe the health professional's role in detecting, assessing, and intervening in domestic violence, child abuse/neglect, and elder abuse.
Understand physicians' responsibilities in issues of abuse and neglect.

An understanding of the concept of community health.

Understand the concept of caring for populations of patients.
Describe principles of population-based medicine.
Compare and contrast care of populations with care of individual patients.
Describe how financial, cultural, and community dimensions affect access to care and priorities of healthcare delivery.
Describe the role and function of public health departments.
Describe the rules regarding reporting of diseases to public health officials.
Describe the concept of food and safety food borne illnesses and the role of public health officials in ensuring the safety of food products.

Knowledge of the importance of exercise.

Define the role of exercise in disease prevention and health.
List the diseases associated with lack of exercise.
List the exercises needed for growth and development across the lifecycle, from neonate through elderly.
Describe the changes in exercise needed for acute and chronic conditions.
Describe the optimal exercise prescription for people with common disabilities at different stages of the lifecycle.
Describe the acute and chronic results of improper or overuse of exercise.
Describe the concept of physical therapy and occupational therapy.
Demonstrate how to obtain an exercise history.
Demonstrate basic skills to counsel patients about changes in exercise.

Recognition of the clinically relevant differences between the genders.

Describe the nutritional needs that are different in women versus men.
Compare and contrast the psychological needs of the genders.
Differentiate the epidemiology, presentations, physical findings, and societal acceptance of diseases in men versus women.
Differentiate the testing needed to diagnose diseases in women versus men.
Describe how dosing intervals, amount of medications, effects on the organ systems, and side effects of medications differ between men and women.

An understanding of the role of race and culture in the practice of medicine.

Describe the nutritional needs that are different in different races and cultures.
Compare and contrast the psychological needs of different races and cultures.
Differentiate the epidemiology, presentations, physical findings, and societal acceptance of diseases in different races and cultures.
Describe how dosing intervals, amount of medications, effects on the organ systems, and side effects of medications differ among races.

Educational Methods

The area of medical knowledge requires an interactive environment for knowledge skills and attitudes to be learned and practiced. A variety of strategies may be required to best facilitate student learning. Knowledge areas may be transmitted in a structured environment such as lectures, videos, or reading. Understanding the meaning of this content requires interactive sessions as well, with opportunities to practice in the clinical situations and reflect on personal values. This could include small- group experiences, allowing articulation of perspectives and effect on patients. Students need to understand their own beliefs, cultural backgrounds, and stereotypes. They need to be exposed to other perspectives. They will need direct patient contact to practice many of these skills and a mentorship relationship with a practicing physician. Experience must be extensive enough to allow students to see a spectrum of disease processes, acute and chronic, early and late stages. They must have exposure to a representative example of different sites and populations, including each group's lifestyle, genders, health risks, and diseases. Concepts that go beyond organ systems need to be taught across all courses, and with a faculty representing different specialties, demonstrating interdisciplinary approaches to patient care addressing all areas that influence health outcomes. Adult learning techniques and practice with evidence-based medicine techniques could be utilized for maximum effectiveness.

Resources

Medical schools have faculty members who have taught the above topics, and frequently these individuals already have identified several useful resources. Some Internet sites are listed below to encourage further exploration of that source of rapidly evolving resources.

A. An investigatory and analytical thinking approach to clinical situations.

B. An understanding of the biomedical basis of disease and disease processes.

C. Knowledge and application of strategies for effective learning and improvement.

D. Knowledge of development and changes across the lifespan.

http://www.nichd.nih.gov/

E. An understanding of nutrition in health and disease.

F. An understanding of the science and management of pain.

G. An understanding of the concept of chronic illness.

H. An understanding of the principles of environmental medicine.

I. Comprehension of normal human sexual function and sexual dysfunction.

http://jama.ama-assn.org/cgi/collection/womens_sexual_function (requires password)
http://pubs.ama-assn.org/cgi/collection/mens_sexual_function (requires password)
http://en.wikipedia.org/wiki/William_Masters_and_Virginia_Johnson

J. An understanding of the concept of prevention and preventive medicine.

K. Knowledge of substance use disorders and other addictions.

L. Understanding of the concept of violence and neglect across the lifespan.

M. Understanding of the concept of community health.

N. Knowledge of the importance of exercise.

O. Recognition of the clinically relevant differences between the genders.

P. An understanding of the role of race and culture in the practice of medicine.

Q. Slide set on ACGME Medical Knowledge:

http://www.apds.org/3-Medical%20Knowledge.ppt (Download PowerPoint file)

Assessment Strategies

Medical knowledge is of ultimate importance, and assessment should be highly visible and very high-stakes, based on explicit expectations of students. Evaluation will require utilization of multiple techniques to address knowledge, skills and attitudes. Videotaping of patient encounters and standardized patient evaluations, participation in small group discussions, oral and written examinations, tests for specific examination skills, observations during patient care, Socratic questioning of individual students, and structured opportunities for individual and group reflection are all methods that can be used.

Faculty Development

Traditional educational practice in medical schools emphasize the organ systems and discipline-based approaches, but faculty development is necessary to ensure effective team teaching approaches, interdisciplinary collaboration, integration of material across disciplines and courses, and focus on patient health outcomes. The integration of these concepts needs to be across the curriculum and in every course rather than adding additional curricular time. Faculty development in adult education techniques may be necessary. Faculty development for role modeling and mentoring techniques should be considered.

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This page last updated November 6, 2004