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

Patient Care

Lead Authors: Scott Fields, MD and Allan Goroll, 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 participate in the comprehensive care of patients' problems in the context of an ongoing continuity relationship. Students must first identify the health needs of patients, across the spectrum of age, gender, and socioeconomic background. This will require patient-centered interviewing techniques for determining patients' needs, including their preferences for diagnostic and therapeutic decisions, and end-of-life decisions in particular. Providing or coordinating care will require a working knowledge of the diverse elements of the health care delivery system, including community resources for care and strategies for coordination. Students also will need to be able to apply basic principles of therapeutic decision making, such as outlining treatment options, listing distinguishing features of the options, describing potential outcomes, and predicting likelihood of those outcomes. Students should understand the evidence that validates key elements of the history and physical and demonstrate a commitment to improving history taking and physical examination skills by regularly seeking feedback on performance. To help patients make therapeutic decisions, students will need to understand the role of pathophysiology and evidence-based medicine in the selection of treatment modalities. For the continuity relationship, students will need to be able to describe the tension between physicians' commitment to individual patients and their responsibility to society to control health care costs.

Competency

Students must work to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Goals

A. Communicate effectively with patients and their families.

Learn the essentials of establishing the patient-physician relationship.

Describe the importance of the patient-physician relationship as the cornerstone of medical care.
Describe strategies for establishing a positive doctor-patient relationship across the life span.
Describe personal and general barriers to taking a nonjudgmental stance on behavioral issues.
Describe the importance of, and demonstrate a patient-centered interview.
Describe elements of the patient-physician relationship that encourage patient trust.
Demonstrate the characteristics of positive regard for patients (respect, genuineness, and empathy).
Describe and demonstrate how the "art" of medicine establishes the doctor-patient relationship, maximizes quantity/quality of information obtained from the patient, and fosters patient commitment to treatment.
Demonstrate each of the three basic functions of the interview: a) gathering data, b) building rapport and responding to patient's emotions, c) education, negotiation, and motivation.
Demonstrate cultural assessment techniques of developing rapport and building a mutual agenda with patients through active listening skills.
Describe how attending to and utilizing nonverbal cues can improve doctor-patient communication.
Describe the importance of sensitively interviewing patients in violent, abusive, or neglectful situations.
Demonstrate appropriate interviewing techniques for detecting and confronting potential violence/abuse across the spectrum of age, gender, sexual orientation, and family beliefs.
Describe how a physician's own feelings and attitudes (e.g. discomfort, frustration, fear of offending, powerlessness, fatalism, or lack of time) can impede effectiveness in identifying or assisting patients who are vulnerable to violence/abuse and neglect, and discuss how clinicians might deal with these factors.

Learn how to obtain essential information about patients accurately and effectively.

Demonstrate interviewing techniques to facilitate rapport and understanding the patient's story.
Demonstrate the components of the medical interview with patients and written history across the life span, including the chief complaint or presenting problem(s), history of present illness; past medical history; family, social, sexual, and spiritual histories; and review of systems.
Describe the importance of and conduct a sexual history in a nonjudgmental manner, with empathy, and without shame or embarrassment.
Recognize physician barriers to obtaining a sexual history and the consequences that might result from such an omission.
Describe and elicit components of a spiritual history and relate to life cycle issues.
Demonstrate the mental status examination and describe its role in interpreting the patient's history.
Describe how to assess landmarks of physical and psychosocial growth and development across the life span.
Describe challenges associated with techniques of obtaining a history from special populations, such as patients with a poor understanding of the English language.
Demonstrate a systematic method for focusing the history and physical examination.
Demonstrate the correct use of medical terminology for the history and physical examination.
Describe common challenges presented by physician/patient interactions during the medical interview.
Demonstrate competence in performing focused and comprehensive physical examination, including the following systems or areas: a) HEENT b) neck c) breast d) cardiovascular; e) pulmonary; f) abdominal; g) pelvic; h) scrotal; i) rectal; j) musculoskeletal; k) neurological; and l) skin.
Describe normal versus abnormal historical and examination findings, and correlate with pathophysiology, in each of the following systems or areas: a) HEENT b) neck c) breast d) cardiovascular; e) pulmonary; f) abdominal; g) pelvic; h) scrotal; i) rectal; j) musculoskeletal; k) neurological; and l) skin.
Describe how to maintain patient comfort, modesty, and privacy for pelvic, breast, scrotal, and rectal exams, outlining methods of doctor-patient interactions and appropriate means of maintaining patient privacy.
Describe and demonstrate a structured approach to performing a comprehensive physical examination.
Describe the rationale for the "screening examination" and list reasons why specific maneuvers are included.
Describe circumstances in which a comprehensive examination is indicated, and circumstances in which a focused examination is indicated.
Describe how problem-solving strategies in the history may parallel the process used to focus the physical examination.
Describe methods to protect patient confidentiality, including legal requirements.

Learn the essential elements of counseling and educating patients and their families.

Describe the importance of an accurate and comprehensive history, including definition of risk factors and coping skills, patient's perspective and stage of readiness for change, and available resources.
Describe principles of injury prevention (e.g., passive versus active prevention) and specific examples such as child restraints, anticipatory guidance, and legislation.
Describe the epidemiology of abuse, violence, and neglect across the lifespan.
Describe the health professionals' role in detection, interviewing, assessment, and response in regard to domestic violence, abuse, and neglect.
Describe the importance of eliciting a substance abuse history.
Demonstrate obtaining a substance-abuse history.
Describe concepts and perspectives underlying clinical understanding of substance use disorders.
Identify counseling areas pertinent to selected patients, including:

Genetics
Oral health (including factors that affect oral health, resulting in ultimate tooth loss, periodontal disease, and oropharyngeal malignancies, and recognition of current barriers that negatively affect oral health care and proposed solutions to circumvent these.)
Geriatrics and end of life care
Mental health
Substance abuse
Sexual practices
Injury prevention
Diet and exercise
Other primary preventive measures, including immunizations and chemoprophylaxis

Describe the genetic contribution to common diseases.
Describe the components of genetic counseling.
Demonstrate the ability to effectively elicit and record family information.
Describe barriers to identification and management of the medical and behavior issues affecting the entire family.
Describe how community and cultural norms relate to health and beliefs of individual patients.
Describe how a patient's presentation may be influenced by biological, sociological, and psychological factors.
Discuss the impact of the physician's family background on the concepts of a) the normal family, b) family dysfunction, c) the physician's communication with families.

Learn the essentials of communicating and working with members of the health care team, including those from other disciplines, to provide patient-focused care.

Describe advantages of an interdisciplinary approach to care, including realizing the benefits of the biopsychosocial model in comprehensive care.
Describe the contributions of various health professionals to complex care situations.
Describe basic communication skills that promote effective teamwork and conflict resolution.
Describe ways in which physicians might effectively utilize the interdisciplinary approach in various practice settings, such as HMOs versus private practice or specialty versus primary care.
Describe the roles of various professionals involved in the comprehensive treatment of patients with severe mental illness and other specific disease states.
Describe ways physicians and health care providers of integrative approaches and therapies (CAM) could best work together to discover an integrated approach to patient care.

B. Make informed decisions about preventive, diagnostic, and treatment interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.

Learn the essentials of formulating a problem list and differential diagnosis.

Develop a thorough but concise problem list based on the history and physical.
Demonstrate a systematic approach to differential diagnosis.
Generate and pursue multiple hypotheses in the interview and physical examination, linking the development of clinical reasoning with pathophysiology.
Describe what is meant by an undifferentiated patient complaint.
Describe why the process of "diagnosis" may, in fact, not address patient's primary concerns.
Describe how attention to the process of the psychiatric interview can improve the accuracy of differential diagnosis and case formulation.
Describe biopsychosocial approaches to diagnosis and treatment of patients and recognize limitations of a strictly biomedical approach to patients.
Understand how one's own preconceptions can influence the course of an interview and one's diagnostic reasoning.

Learn the essentials of formulating and implementing a management plan.

Describe patient, physician, and systemic barriers to successfully negotiating treatment plans and patient adherence, including the physician contribution, and what strategies may be used to overcome these barriers.
Define the following terms: compliance, adherence, fidelity, maintenance, self-efficacy, empowerment, therapeutic alliance, patient cooperation, partnership, and patient nondisclosure.
Describe patient nonadherence to health care regimens in different cultural groups, different patient populations, acute and chronic illnesses, and with different treatment regimens.
Describe methods of measuring patient nonadherence: clinician perception, patient self-report, medication measurements, clinical outcomes, direct chemical analysis, medication monitors.
Describe how the following variables influence patient adherence to treatment plans: demographic characteristics, patient/physician congruence in problem definition, patient concerns, cost, complexity of treatment, duration of treatment, and side effects.
Describe the influence of psychosocial variables (e.g., patient-provider interaction, physician frustration, patient interest in alternative health care, effects of information and education, behavioral/environmental factors, and health belief models) on patient adherence to treatment plans.
Demonstrate methods of achieving consensus: confirming common understanding by summarizing and checking, educating patients, tailoring regimens, cueing, patient self-monitoring, contingency contracting, patient empowerment, and patient self-efficacy.
Describe how the symptoms of chronic and severe mental illness can impair activities of daily living such as obtaining adequate food and housing, money management, employment, family and social functioning, and adherence to treatment plan.
Describe how the symptoms of even mild mental illness can impair activities such as self-care, adherence to treatment plan, and quality of life.
Describe specific treatment interventions that can enhance psychiatric rehabilitation and improve community adjustment for patients with schizophrenia and bipolar disorder.
Describe the range of community and clinical resources available for treatment of substance abuse for individuals with and without health insurance coverage.
Identify resources available to help physicians and families regarding child abuse including those in rural and/or underserved areas.

Learn how to access and use best evidence to inform and support decision making and patient education.

Demonstrate the use of the medical literature to:

Answer clinically relevant questions.
Formulate a differential diagnosis regarding a chief complaint.
Develop a diagnostic strategy.
Determine potential treatment strategies.

Demonstrate principles of clinical decision-making by showing how to:

Articulate the logic behind the process of development and prioritization within the differential diagnosis.
Communicate and defend a diagnostic approach based on likelihood of diagnosis, sensitivity and specificity of medical testing, relative costs of medical tests, and patient preferences/values.

Describe and demonstrate how the "science" of medicine leads to applying reliable diagnostic standards and predicts the necessary care to be provided.
Describe how there are many ways to work-up medical complaints (testing) and that choice of medical test is critical both in regards to patient care and to medical economics.
Describe how the use of drugs should be based on logical assessment of potential etiologies for the illness and cost of the medication.

Learn the details of preventive measures, including criteria for screening, best approaches, and cost-effectiveness.

Compare and contrast the concepts of health promotion in individuals and populations.
Describe the physician's role in health promotion and preventive medicine activities.
Describe the principles and components of prevention, screening, and health maintenance in health care across the lifespan and in different populations.
Describe the importance of the periodic health examination and utilization of the preventive services.
Identify screening strategies recommended for selected patients, using history, physical exam, and lab/diagnostic procedures.
Describe methods that can assist physicians in evaluating the effectiveness of clinical preventive services.
Describe the role of behavioral change as a cornerstone of health promotion, including primary prevention.
List the risk factors for the leading causes of death and how patients can alter modifiable risk factors.
Describe the principles of promoting behavior change for health related behaviors, such as diet, exercise, smoking, sexual activity, stress management, and violent behaviors.
Describe the principles and components of injury prevention (e.g., passive versus active prevention) and specific examples such as child restraints, anticipatory guidance, legislation, and engineering.
Describe the epidemiology of abuse, violence, and neglect across the lifespan, genders, and populations.
Describe the health professional's role in detection, interviewing, assessment, and response in regard to violence, abuse and neglect toward intimate partners, elders, children, the disabled, or other vulnerable individuals.
Describe the following:

Principles of active and passive immunity
Vaccine-preventable diseases
Principles of disease prevention through universal and targeted vaccination
Diseases with emerging antimicrobial resistance
Guidelines for the judicious use of antibiotics in an era of increasing antibiotic resistance

Learn the roles of some major diagnostic and procedures and interventions, including rationale, indications, complications, and necessary basic skills of performance and interpretation.

Demonstrate a basic strategy to systematically evaluate electrocardiogram tracings.
Define the 12 leads on a standard EKG.
Demonstrate how to calculate heart rate, determine an electrocardiograph axis, measure the PR, QRS, and QT intervals, and a strategy to identify heart rhythm on an EKG.
Describe the EKG findings of myocardial ischemia.
Describe the anatomy of the thorax seen on chest X-ray.
Demonstrate a standardized approach to chest X-ray reading.
Identify common pathological findings seen on chest X-ray and describe them accurately.
Describe the pulmonary function test findings compatible with obstructive and restrictive mechanics of breathing.

Educational Methods

The area of Patient Care requires an experiential environment for the knowledge, skills, and attitudes to be learned and practiced. For this reason, a clinical preceptorship should serve as the cornerstone to best facilitate student learning. Patient Care may be reinforced by a mentorship relationship with a practicing physician. Knowledge areas may be transmitted in structured environments such as lectures, videos, readings and computer-assisted self-study modules. Small group experiences will enable participants to articulate perspectives, not only as a health care provider, but also to discuss the effects on patients. Understanding the meaning of this content requires an environment providing the opportunity for application to clinical situations and reflection on personal values. This experience must be extensive enough to allow students to see a breadth of behaviors, to create a relationship with enough depth that allows for discussion of these personal issues, and to anticipate personal contexts in which the student's patient care knowledge, skills, and attitudes would be most challenged.

Resources

Books

Bickley LS, Hoekelman RA. Bates' Guide to Physical Examination & History Taking. Lippincott Williams & Wilkins Publishers, 8th ed.(August 15, 2002)

Web Sites

Physical Examination and History Taking

Evidence-Based Medicine

Medical Informatics

http://www.mieur.nl/mihandbook/r_3_2/handbook/homepage_self.htm

Prevention

http://nccam.nih.gov/health

EKGs

http://www.ecglibrary.com/ecghome.html

Chest radiology

Assessment Strategies

Evaluation of Patient Care requires utilization of multiple techniques to address knowledge, skills, and attitudes of future physicians. Direct observation is the key to evaluation of many of the skills outlined above. This is an area where faculty have decreased their involvement as pressures in other aspects of their roles have increased. Faculty must return to this foundational method of monitoring the growth and development of patient care skills.

Videotaping of patient encounters and standardized patient evaluation are methods that enable assessment of patient care skills.

Structures within the curriculum must be developed that encourage systematic feedback to students about patient care knowledge, skills, and attitudes. All sources of input are viable, but the key is formative and summative evaluations by clinical preceptors.

Faculty Development

Faculty development should be focused in the following areas: role of a mentor and setting appropriate expectations regarding student involvement in patient care including documentation in the medical record, strategies for evaluation, and methods for providing formative feedback to learners regarding professional behavior.

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated November 6, 2004