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Primary Care Clerkship

Mohamud Verjee, M.D. Course Director
Deema Al-Sheikhly, MRes, Clinical Curriculum Coordinator

Welcome to the experience of the primary care clerkship, intimately involving family medicine, an area of medicine at the leading edge of care. You are assured of a clerkship with a difference.

In your final year, you will be excited and will have thought about your future career. Whatever field you eventually choose, we need every graduating physician who studies at WCMC-Q to derive sustained professional fulfillment, be trained to the best of his or her ability, and to be able to apply that knowledge in the clinical setting, linked with the sense of the inquisitive, with an appetite for lifelong learning.

Primary care in the community requires great interpersonal skills, empathy, a wide breadth and depth of knowledge, a professionalism of attitude and practice both inside and outside the hospital setting, and a sense of adventure. Now opportunities are bountiful - to serve the community, complete research with evidence based medicine, chances to develop a specialty topic such as obstetrics, endoscopy, anesthetics, or child development to name but a few. Collegiality amongst primary care physicians is at its best when everyone contributes, learns, and provides the many services to their patients with a sense of pride and enjoyment. Patient centered care is our model.

I really want you to enjoy these six weeks. Don’t be afraid to discuss any problems with your preceptor. He or she is there to help you, and you are welcome to contact me at any time.

Seminars and lectures for this clerkship will be held in WCMC-Q unless otherwise noted. Please check your e-mails carefully the night before the lectures regarding any last minute changes in times or topics. This will be the only guide you will receive, and your punctual presence is expected at the allotted times for teaching.

The motivation behind the creation of the new Primary Care Clerkship is largely twofold. First, public debates and attempts at health care reform have shed new light on the importance of the primary care physician. In addition, it has been difficult for third year medical students assigned to traditional inpatient oriented clerkships to obtain a good understanding of ambulatory medicine in their field of choice. We anticipate that a dedicated six-week rotation through the various ambulatory arenas will facilitate career choices.

The Primary Care Clerkship is a six-week series of outpatient and health clinic experiences that will emphasize three weeks of Medicine (including Geriatrics) and three weeks of Family Medicine (including, ER/Urgent Care, and Ob/Gyn) as well as exposure to the Community Medicine program (psychosocial and preventive).

The learning objectives of the clerkship are as follows:

Objective #1:

Students will learn to diagnose, generate differentials and initiate cost-effective management strategies for a broad array of common medical conditions and chief complaints that present in the ambulatory setting.

Plan:

Students will participate, with preceptor supervision, in the care of acutely symptomatic outpatients. Examples of appropriate and important chief complaints to focus on include: cough, dizziness, palpitations, chest pain, dyspnea, upper respiratory symptoms, fever, chronic fatigue, abdominal pain, diarrhea, GI bleeding/anemia, dysuria, vaginitis, sexual dysfunction, joint/neck/lower back pains, headache, leg edema, red eye, common dermatologic issues such as acne, fungal infections and dermatitis. Students are expected to have at least ten (10) such urgent visit/chief complaint-oriented encounters during the 6 weeks.

Objective #2:

Students will be able to manage multiple chronic medical diseases and risk factors in an ambulatory setting.

Plan:

Students will be exposed to patients who are being sequentially followed for chronic diseases such as hypertension, diabetes, lipid disorders, congestive heart failure, asthma/COPD, thyroid disease, osteoporosis, renal insufficiency. Students should have exposure to at least five (5) such patient encounters where chronic disease and medical morbidity management is emphasized.

Objective #3:

Students will foster health promotion by applying appropriate well care guidelines for specific patient populations and counseling about specific patient behaviors.

Plan:

Students may participate in the application of immunization guidelines for pediatric and adult patients and may participate in discussions regarding cancer screening, protocols for breast, colon, cervical and prostate cancers. Students may participate in counseling patients regarding diet, obesity, exercise, smoking cessation, drug and alcohol abuse and safe sex. A minimum of at least five (5) such encounters, where well care and counseling is emphasized, is expected. The lecture series will focus on the evidence behind many guidelines and topics such as post test probability, absolute vs. relative risk reduction and number needed to treat or screen (NNT and NNS will be emphasized.)

Objective #4:

Students will elicit psychosocial histories and functional assessments from patients with preceptor supervision and recognize psychiatric illness in a medical practice.

Plan:

Students will perform functional assessments on elderly patients during the scheduled geriatric activities. Students will be exposed in the various clinics to patients who suffer from depression, anxiety and somatization. Five (5) such patient encounters are expected.

One of the fundamental goals in the design of this clerkship has been to ensure an active learning experience for each student. In most instances, the student will be the first person to see the patient. Often patients have been specifically scheduled to see you, therefore ATTENDANCE IS MANDATORY! In most clinics, you will not be merely shadowing a Consultant or Specialist physician. This would allow you only to passively observe the care they are giving their own patients. Instead, you will function very much as an intern. You will be asked to complete a history and physical examination on a patient, after which, you will be supervised by a Consultant or Specialist physician in the clinic.

A lecture series will complement the clerkship clinical experience. Five afternoon sessions per week have been set-aside for Clerks on rotation to have formal teaching including journal reviews. These didactic sessions will draw heavily from readings from the required textbooks. Assessment of students will be based upon evaluations by Consultants that have supervised the students in various clinics, as well as a final written examination and an essay based take-home examination.

Attendance at Clinical Sites: Attendance is mandatory. If you are ill or unable to make a session you must contact Deema Al-Sheikhly on 492-8345. All absences must be excused promptly. You will be required to make up any unexcused/unexplained absences.

Your grades will be comprised of the following components.

• 50 % Tutor Evaluations: You will be responsible for providing blank evaluation forms (Student assessment and DOCS) to each of your preceptors. Preceptors do not need to fill out a form for every session. The more evaluation forms you hand out to different preceptors, the more accurate our portfolio of your clinical work will be.
• 25% National Board Exam (NBME) Subject Review in Family Medicine: The material on this exam will be drawn from the lectures, readings and clinical experiences. Evaluations will be assessed centrally and final marks communicated.
• 25% Take Home Essay Questions: The questions will be distributed midway through the course. Topics will change for each six-week block of the Primary Care clerkship. We invite you to discuss, debate and investigate topics freely among yourselves. However, you are expected to hand in your own individual work, at the end of your rotation. Your answers should be in your own words and reflective of your own individual thought processes.

Note: Attendance/punctuality and active participation in lectures and seminars will affect your grade on an individual basis. This has been particularly true in the past for students who were on the borderline between grades. In addition, all unexcused absences are noted in your permanent record.

Should you have any leave requests for example to attend an examination, attend a meeting, or present a poster or paper, you should address your request in writing to the Director of the Primary Care Clerkship stating your reason, via e-mail prior to the event. If in excess of two days is required, you must also inform Mr Eric Fry, Student Affairs Director for formal approval. Any leave taken without approval even if bona fide will be regarded as being absent, and will be marked accordingly. Time lost from teaching sessions will have to be made up with extra input from the Clerk as directed.

"The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation." (Osler, 1906)

Medical School training in any University should be undertaken by its students with the patient’s best interest at heart. At Weill Cornell Medical College in Qatar, there are special community and cultural issues which need to be fully respected, with respect to dress, behaviour and general and personal conduct.

Your sensitivity and awareness of Qatari society and culture should be uppermost in your minds when professional contact is made and in the application of your clinical skills during training.

1. Hypertension in the adult – benign essential, accelerated
2. Diabetes Mellitus – Types 1 & 2
3. Urinary tract infections (UTI) Cystitis/Dysuria
4. Sexually transmitted diseases – chlamydia, hepatitis, GC, HIV
5. Low back pain – musculoskeletal (MSK) or degenerative disc disease
6. Headache/migraine
7. Abdominal pain – upper and lower quadrants
8. Joint pain and polyarthropathy
9. Depression/psychosis
10. Endocrine disorders – hypothyroidism, hyperthyroidism, Cushing’s
11. Vaginal discharge/atrophic vaginitis
12. Obesity – youth and adult
13. Anxiety disorders - MDE/GAD
14. Pharyngitis/sore throat
15. Upper respiratory infections
17. Cough/asthma/recurrent wheezing/allergies
18. Elderly patient issues – frailty, senility, dependency, abuse, social
19. Diarrhea – functional/infective
20. Skin disorders – benign and malignant - MM
21. Lower respiratory infections
22. Red eye – iritis, infections, trauma
23. Minor trauma – sprains, bruises, lacerations
24. Prenatal care – primigravida/multipara
25. Coronary artery disease – Angina/MI
26. Breast disorders – benign and malignant
27. Prostate disorders – benign and malignant
28. Chronic fatigue
29. Earache/otitis media
30. Anemia

The learning experience will consist of much more than just the above, mostly from clinical experience, in both community health clinic and outpatient department settings. You are advised to log each new presentation, and build on the clinical condition with a sense of enquiry, and investigation, expanding your current level of information and applying your skills as well as increasing them. Primary Care with family medicine knows no bounds, and no curriculum can teach you everything. It is thus beholden upon each Clerk to learn and read at every given clinic and study period respectively, while being discerning and effective with the best use of your time. I stress that the above list is not exhaustive, and should not be regarded as “complete”.

Eliciting both the disease and the illness experience –

• Establish rapport with the patient – communicate effectively
• Disease – take the history, examine the patient, and have a differential diagnosis
• Illness – respond to verbal cues – what are patient expectations? How do patients express their symptoms? Look at fears, ideas, expectations and effects on functioning which all concern the “illness experience” (FIEF)

Understanding the whole person –

• Delve into the patient’s life in terms of development and experiences
• What effect does this have on the presenting illness?
• Can family members help?

Finding common ground

• Extract information effectively in order to have a management plan
• Elucidate the problem priorities
• Share your ideas on goals of treatment and decision making
• Cooperate with the patient – do not bargain but interact
• Applying prevention and health promotion
• Promote health
• Try to prevent disease progression
• Attempt risk reduction
• Be realistic – common things commonly occur

Professionalism in Primary Care

• Conduct yourself to the highest standard always with patient care
• Respect confidentiality at all times – no corridor chat
• Use all appropriate resources available – no cutting corners
• Highest moral and ethical values upheld at all times
• Equality of level of care and best application to all regardless of means or circumstance
• Enlist assistance where necessary – not regarded as a failing
• Support colleagues where you can and do not denigrate them at any time

New developments – Lifelong learning

• CJD
• H5N1
• SARS