It is widely held
that to have an understanding of one’s success it is necessary to have a
standard for measuring performance. Although we "felt" that our
graduates were adequately prepared for the next level of their training,
we had no specific codification of areas in which as graduates our
students should possess an appropriate level of competence. The purpose
of this document is to provide just such a codification.
It is not exhaustive and
is not intended to be, and it often is not explicit regarding the level
of competence that is expected. Yet, it should provide guidance for both
students and faculty about competency areas that should be "made
available to" students. In keeping with the need for students to develop
habits and skills of life-long learning, students will be expected to
"avail themselves of" all competency areas that are not "provided to"
them in their clinical education program.
In the process of
developing the document, we recognized that our curriculum fails to
include some areas needed by physicians, particularly those expecting to
practice in the 21st century. We are addressing those deficiencies and,
as this is a living document, will make modifications in accordance with
the needs of students, the health care community, and society.
This document is the product of the
efforts of many people. Its origin can be traced to documents prepared
by professional societies of various disciplines, tailored to the needs
of those
disciplines at this institution. Through
a process of de-coupling the competencies for the respective
disciplines, eliminating redundancies, establishing an organizational
framework, and honing the results, we arrived at the final document.
Although the clerkship directors at all three campuses were involved in
the process, the following individuals (listed in alphabetical order)
devoted time and effort to participate in extra reviews of the document,
several noontime sorting meetings, development of an organizational
scheme, etc.: Roger Berkow, MD, Eta Berner, EdD, Dennis Boulware, MD,
Sharon Phelan, MD, Marlon Priest, MD, and Bill Weaver, PhD.
Because it is important for you to
acquire the knowledge and skills specified in this document and because
doing so is YOUR responsibility, it is suggested that you keep this
document handy and check as a reminder of the areas in which you will
need to gain proficiency. Blocks have been placed to the left of each
competency area in order to enable you to check off when you feel that a
competency has been observed/performed/mastered. The document has been
produced in a size to make it less cumbersome and more usable.
Upon graduation, we expect our students to demonstrate competency in the
following general areas:
The student will demonstrate
the importance of, and skill in producing and handling
confidentially and appropriately, oral and written communication
with and to patients, colleagues, and the community by doing the
following:
Discussing physician, patient, and
family factors (including patients' hidden agendas) which
contribute to difficult physician/patient/family relationships and
demonstrating interpersonal skills that will enhance communication
between the physician and the patient and his/her family.
Explaining how communication with
patients, family, and community may differ in rural health care
settings and other cultural/ethnic settings.
Professionally and compassionately
relating news of a serious acute or chronic illness or a
congenital abnormality to patients and their families.
Identifying, organizing, and
recording accurately in the problem-oriented patient record (paper
or paperless) the information needed to appropriately address the
patient's problem/condition.
Utilizing the existing medical
information to prepare appropriate and meaningful follow-up and
consultation notes.
Explaining the roles of primary
care and subspecialists in the overall care of patients, including
the responsibilities of the primary care physician for
coordination of patient care during consultation and referral.
Working and communicating
effectively and professionally with the health care team,
colleagues, consultants and agencies, patients’ employers, and the
patient and family.
The student will demonstrate an
understanding and appreciation of ethical issues which are essential
to professional delivery of patient care by doing the following:
Developing a productive
interaction with patients by valuing the patient and his/her
input, encouraging patient autonomy on the basis of informed
choices under the guidelines of informed consent, maintaining
confidentiality of patient information, and maintaining continuing
personal responsibility for the patient's (and family's) health
care.
Describing the professional and
ethical issues facing physicians when encountering and treating
the economically disadvantaged (poor, lack of health care
insurance, homeless, Medicaid, Medicare).
Describing the professional and
ethical issues facing physicians under traditional fee-for-service
and managed care systems in life and death decisions (brain death
and vegetative states) and weighing the needs of patients v.
society.
Identifying and presenting in an
unbiased manner potentially controversial health care issues,
including (1) Reproductive choice, (2) Maternal-fetal conflicts,
(3) Religious conflicts with provider, and (4) medical team
conflicts.
Recognizing and helping in
physician impairment (drug, alcohol, psychological, family
problems).
The student will demonstrate at
least a basic level of competence in the skills--medical
interviewing, history-taking, physical examination, and information
organizing and recording--which are essential to recognition,
definition, and management of the wide spectrum of problems seen in
the practice of primary care medicine. In addition to overall
competence in the above-mentioned skills, the student must be able
to obtain, organize, and record information on the following
specific topics:
1. History:
Developmental screening and
childhood growth patterns (height, weight, and head circumference)
Psychiatric history
Sexual history and, for women,
menstrual and obstetrical history
Family history as it relates to
risk factors for disease and possible congenital anomalies/risks
Screening/history for frequently
overlooked problems including behavioral problems in
children/adolescents, bleeding disorders, and sleep disorders
The student will demonstrate an
understanding of the need for and an ability to make basic
diagnostic and treatment decisions on the basis of appropriate (but
limited) clinical data by (1) formulating a differential diagnosis
using history and physical exam data, (2) developing a prioritized
problem list, (3) applying principles of sensitivity, specificity,
pre-test predictive values and cost considerations in selecting
tests, (4) interpreting test results, (5) making diagnostic-
decisions, (6) initiating appropriate consultation/referral when
needed and (7) developing a treatment plan that responds to the
ongoing changes in patients and their illnesses. The student will
also utilize appropriate information resources to assist with the
diagnostic process. In addition, the student will demonstrate
knowledge of what they measure, indications, and how to interpret
the following:
Tests using other bodily samples
(urinalysis; body fluid cell counts; lumbar puncture; Pap smear;
pregnancy test; peritoneal lavage);
Imaging studies (Chest X-ray;
plain abdominal X-ray; Abdominal x-rays with contrast [upper GI
series; Barium enema; IVP; cholecystogram], ultrasound including
pregnancy-related diagnoses) CT/MRI; other special imaging studies
[mammography; Nuclear medicine studies arteriography]);
Physiological tests (pulmonary
function tests; ECG; EEG/EMG/evoked response);
Tests for evaluation of
neuropsychiatric symptoms (neuropsychological testing and
psychological evaluations including personality tests and
inventories) and organize all data using the five axes of the
DSM-IV.
The student will demonstrate both
understanding of screening and health maintenance for individuals
and families by doing the following:
Identifying health risks in
patients, families, and communities using probability estimates of
disease prevalence specific to the geographic and socioeconomic
community of the practice location and natural history of common
problems and illnesses over the course of the individual and
family life cycles and using this information for health
supervision based on age and environment.
Demonstrating basic knowledge for
selecting protocols and strategies for risk factor modification in
patients, families, and communities.
Using appropriate screening tools
and protocols for health maintenance in specific populations and
age groups, including encouraging patients seen for episodic or
acute illness to seek continuing medical care and identifying
appropriate indications and schedules for preventive screening,
health maintenance activities.
More specifically, the student
will demonstrate knowledge and skills on the following topics:
Risk factors for common chronic
illnesses, such as stroke, hypertension, cancer, heart disease,
diabetes.
Indications and interpretation
of periodic screening tests including the impact of age, gender,
ethnicity and other risk factors.
Routine prenatal care and
deviations from the routine, anticipated course.
Use and interpretation of tests
for neonatal screening, developmental screening, hearing and
vision screening, lead screening, and drug screening in the
infant and child.
The impact of life style choices
(e.g., nutrition, exercise, sexuality, substance use and abuse)
on health and disease.
Principles of
guidance/intervention for moderation of life style choices, age
appropriate behavioral concerns, puberty, injury prevention and
home safety.
Appropriate immunizations and
their side effects for infants, children about to enter school,
adolescents, adults, and the elderly.
The student will demonstrate an
understanding of the basic principles of pharmacologic management of
common disorders, use critical pathways, when appropriate, to design
basic treatment programs. The student also needs to do the
following:
Specify the effects of drugs and
toxic agents on the nervous system, including the drugs used to
treat neurological conditions themselves.
Identify pharmacokinetics and
volume distribution of medications in the pregnant woman, utilize
the pregnancy classification system in the PDR to select drugs,
including certain drugs and environmental agents that may be
teratogenic.
Calculate a drug dose for infants,
prepubertal children, and the geriatric population.
List the most common generic types
of medications used for management of each of the following
uncomplicated conditions: Otitis media, Wheezing, Conjunctivitis,
Allergic rhinitis, Urinary tract infection, Impetigo, Eczema,
Fever, Streptococcal pharyngitis, Acne, Bronchitis/ Pneumonia,
Sinusitis.
Summarize the indications, basic
mechanisms of action, common side effects, and drug interactions
of the following classes of psychotropic medications: anxiolytics,
antidepressants, antipsychotics, lithium, anticonvulsants,
anticholinergics, beta blockers and stimulants.
Identify the basic pharmacology of
analgesic and anesthetic agents.
Write a prescription and check for
interactions using drug database programs.
The student will demonstrate an
understanding of, appreciation for, and skill in patient education
as means to involve patients in decision-making, enable and
encourage them to accept personal responsibility for their own
actions regarding their health care, and elicit behavioral
compliance. The student will also describe the role of the primary
care physician and other members of the health care team in patient
education and health promotion in, but not limited to, the following
general areas:
Injury Prevention: Seat
belt use: Domestic violence/child abuse; Home safety
Prevention/Health Screening:
Breast self-exam, mammograms, Pap smears; Testicular self-exam,
prostrate screening protocol, colon cancer screening, risk factors
for cardiovascular disease and cerebrovascular disease
Hospital discharge education:
Postpartum care, breastfeeding, wound care, use of medications,
activity restrictions
Chronic conditions
including chronic or recurrent pain syndromes
In addition to understanding when
they are appropriate, the student will demonstrate the ability to
perform, using sterile technique when indicated, the following
common technical skills:
Suture a simple laceration with
interrupted sutures.
Insert a nasogastric tube and
confirm appropriate placement.
Place a peripheral IV.
Place and remove skin staples.
Establish an adequate airway.
Perform basic CPR for adult and
child.
Demonstrate surgical scrub
techniques.
Perform vaginal delivery.
Perform venipuncture and arterial
puncture, including arterial blood gases.
The student will: (1) demonstrate
an ability to recognize a situation requiring rapid intervention,
(2) take the appropriate steps to provide emergency care, and (3)
explain the pathophysiological and other reasons for particular
management approaches, and (4) explain methods of monitoring
effectiveness of therapy and avoidance of complications. Specific
areas that the student should be prepared to address are patients
presenting with the following:
Altered mental status.
Neurologic emergencies, including coma, meningitis, status
epilepticus, CNS trauma, increased intracranial pressure, acute
visual failure, neurogenic respiratory failure, and spinal cord
compression.
Potentially life threatening complaints, including acute
abdominal pain, chest pain, acute respiratory distress,
alterations in consciousness, patterns of weakness and numbness,
disturbances of visual perception, and disturbances of ocular
mobility.
Cardiopulmonary collapse, including arrest in the newborn and
including basic CPR for all ages.
Hemorrhagic shock, either obstetrical or surgical.
Septic shock.
Toxic ingestion (type, route, amount, and timing), including
knowledge of the poison control center and other information
resources in the management of a patient with an ingestion.
Childhood emergency, including acute clinical presentation and
initial diagnostic assessment: shock, ataxia, seizures,
delirium/coma, airway obstruction/respiratory distress, and apnea.
Psychiatric emergency, including initial management.
Initial basic resuscitation for burn victims and knowledge of
the criteria for referral to a burn center.
Trauma: basic fundamentals of initial evaluation and
management.
The student will demonstrate an
understanding of the epidemiology of and chronic debilitation caused
by violence and trauma in the context of society and the family and,
in so doing, will be able to do the following:
Recognize, evaluate, and treat
appropriately trauma patients, including cranial, spinal, motor
vehicular, penetrating wounds.
Recognize patterns and common
presentation of domestic violence (particularly against women),
understand immediate and long-term consequences of assault, and
identify local resources for referral, legal advice, women's legal
rights (state policy).
Provide anticipatory guidance
about accidental injury prevention to the family of an infant, a
toddler, a preschooler, school age child, and adolescent and
direct injury prevention strategies to older children/adolescents.
Recognize patterns of and know how
to elicit information on which to diagnose non-accidental injuries
and abuse in children and know the ethical and governmental
responsibilities of physicians in identifying and reporting
suspected child abuse.
Recognize patterns and evidence of
elder abuse and neglect.
The student will demonstrate a
basic understanding of issues relating to the care of critically ill
patients and patients before and after surgical procedures, with
emphasis on assessing the acuity, and, where possible, the prognosis
of the clinical problem as it relates to need for immediate
management and the requirement for expert assistance. In so doing,
the student will demonstrate skill in the care of patients
presenting with/for the following:
Congestive heart failure.
Myocardial infarction.
Stroke and transient ischemic
attacks.
Serious complications of labor and
delivery, including pre-eclampsia, preterm labor, premature
rupture of membranes, hemorrhage, abruption, fetal distress,
dysfunctional labor, and shoulder dystocia.
Shock, including hemorrhagic,
septic, cardiogenic and neurogenic.
Ataxia, seizures, delirium, and
coma.
Airway obstruction, respiratory
distress, and apnea.
Pulsatile abdominal mass.
Pre-surgical work-up, including
the following:
Evaluation of surgical risks
factors and indications for surgery, including coronary artery
disease, malignancies, joint complaints.
Principles of informed consent
and documentation.
Anesthesia choice and management
of potential serious complications with attention to the unique
situations of pediatric, obstetric, and geriatric anesthesia.
Post-operative care, including
principles of fluid management, nutrition considerations,
management of drains, wound healing (steps, time course, and
care), charting, patient education, and including the following:
Risk factors for and management
of post-operative infection.
Indications for instituting
mechanical ventilation.
Pain management.
Indications for and principles
of blood product transfusion, including fresh frozen plasma.
In a variety of medical
situations, the student will demonstrate a basic understanding of
fluid management by doing the following:
Obtaining historical information
and physical exam findings to assess state of hydration.
Explaining the clinical
consequences of electrolyte disturbances, including hypernatremia,
hyponatremia, hyperkalemia, and hypokalemia, and discussing the
effect of pH on the serum potassium.
Using knowledge of the
electrolytic composition of various visceral fluids to calculate
and write IV orders for initial fluid replacement and maintenance,
with particular attention to patients with dehydration from
gastroenteritis and diabetic ketoacidosis, septic shock,
hypovolemic shock, and spinal shock.
The student will demonstrate an
understanding of common acute and chronic illnesses and the impact
of chronic illness on the patient, family, and society, which will
include recognizing the importance and complexity of longitudinal,
comprehensive, and integrated care of patients with chronic problems
which involves multiple medications and simultaneous management of
chronic and acute illnesses. The student will:
Describe the skills and
information required to develop, in conjunction with the patient
and patient's family, a chronic disease management plan that
maximizes functional outcome and quality of life.
Understand the impact of chronic
illnesses on school attendance and cognitive function and
development in school-age children.
The student will describe the
etiology, epidemiologic features, common signs and symptoms,
differential diagnosis, and for psychiatric disorders the DSM-IV
nomenclature, and will demonstrate how to use a focused,
problem-oriented assessment to diagnose and initially manage
(including when and how to make referrals) the following common
acute and chronic illnesses/complaints/ findings:
Autoimmune disorders:
SLE and rheumatoid arthritis
Neurological problems:
epilepsy and seizure disorder, multiple sclerosis, myasthenia
gravis and polymyositis, narcolepsy and other sleep disorders,
pain syndromes (e.g., neck and low back pain, especially those
from herniated cervical or lumbar discs, carpal tunnel syndrome,
Trigeminal neuralgia, and other sites of chronic pain),
neurologic complications of systemic illness, headaches
(especially migraines), dizziness and vertigo, dementia,
Parkinson's disease, peripheral polyneuropathy.
Female reproductive
problems: Pre-conception counseling for women with chronic
common medical conditions (e.g., HTN, DM, asthma) affecting the
prenatal course and delivery, common causes of acute and chronic
pelvic pain (endometriosis, pelvic infections, ovarian
neoplasm); common breast complaints (mass, pain, and nipple
discharge); common causes of abnormal vaginal bleeding patterns
(complications of pregnancy, systemic illness, medication,
disorders of genital tract); primary and secondary amenorrhea;
vaginitis.
Psychiatric problems:
schizophrenia, mood disorders, anxiety disorders, personality
disorders, substance abuse disorders, psychophysiologic
disorders, eating disorders, somatoform and factitious
disorders, and behavioral/school problems in children.
Nutritional problems:
Obesity, eating disorders, special nutritional concerns for
children, geriatric population, and individuals with chronic
disease.
The student will demonstrate an
understanding of the principles of hospital admission and skill in
the inpatient admission work-up and subsequent management of the
following problems:
10. Special Problems of
Newborns: Jitteriness, jaundice, lethargy or poor feeding,
respiratory distress, cyanosis, bilious and non bilious vomiting,
hypoglycemia, and sepsis.
The student will demonstrate an
understanding of the basic principles of infectious disease
diagnosis and management, including attention to universal
precautions and particular application to the following
diseases/conditions:
-Meningitis and encephalitis -Pneumonia/ Bronchitis
-Urinary tract infection
-Infectious agents as they pertain to pregnancy (HIV, rubella,
CMV, group B strep, herpes)
The student will demonstrate an
understanding of the epidemiology (including risk factors,prevalence by age, gender, race) screening, presenting symptoms,
diagnostic and management approaches for common neoplastic
conditions and potentially neoplastic presentations
Common neoplastic conditions:
Common cancers (breast, prostate, colon, lung, gynecologic
melanoma and other skin cancers); Brain tumors; Benign neoplasms
of the breast, ovary, uterus, cervix, and vulva; testicular
masses; Spinal cord tumors; Cancer-related pain.
The student will demonstrate an
understanding of the physiological effects on patients and the daily
living effects on patients and their families of alcohol, tobacco,
and drugs of abuse and initial skill in counseling patients and
their families concerning the following external substances:
Physiological effects of: Alcohol,
Nicotine, Cocaine, Narcotics, and other drugs of abuse.
Daily living effects of alcohol,
tobacco, and illegal and illicit drugs on the following:
The student will demonstrate
(1) an understanding of nutritional principles and needs of patients
of different ages and medical conditions, (2) skill in obtaining a
routine diet history, and (3) skill in addressing and educating
patients and their families about nutritional needs in the following
medical situations/conditions:
Post-operative care
Pregnancy and postpartum,
especially breastfeeding
Post-injury (metabolic response
and nutritional needs)
Indications for parental
nutrition/total enteral nutrition (advantages, disadvantages)
Medical disorders including
chronic bowel diseases, morbid obesity, dyslipidemia, diabetes,
renal or liver failure
Geriatric nutritional issues.
Special needs of children:
Breastfeeding
Formula feeding (including caloric adequacy)
Cow’s milk
Solid additives
Prevention and treatment of common pediatric mineral (iron,
fluoride, calcium) and vitamin deficiencies
Nutritional assessment beyond infancy (including daily diet
diary).
The student will demonstrate an
understanding of the role of genetics in many disorders by doing the
following:
Determining which data from
history and physical exam and which laboratory tests are
appropriate when evaluating a child with a possible common genetic
disorder or a congenital malformation.
Identifying those
diseases/conditions that are determined or heavily influenced by
genetics.
Identifying those
diseases/conditions for which screening as disease risk assessment
is appropriate.
Identifying those
diseases/conditions that have genetic implications for offspring.
The student will
demonstrate an understanding of the role of age in recognizing,
diagnosing and appropriately managing patients with varied
abnormalities and diseases, including the following specific issues
for the various age groups:
Infants/Children
Developmental
evaluation of patients from infants to adolescents, recognizing
growth and maturational milestones.
Initial evaluation
of a child with "failure to thrive".
Communication with
peripubertal adolescents and their parents the most important
adolescent developmental changes and, performance of the sexual
maturity rating (Tanner).
Evaluation of a
child with delayed pubertal development.
Adolescent/Adult
Normal life cycle
physiology and how it impacts on the pathology with particular
emphasis on menstrual cycle, puberty, and menopause.
Physiological,
emotional, and societal influences of sexuality throughout life
stages and their relationship to illness and health in traditional
and alternative expressions of sexuality.
Elderly
Cardiovascular
problems of the elderly, including temporal arteritis, stroke.
Dementia,
pseudodementia, and depression, with an understanding of how they
influence other medical conditions, treatments, and living
arrangements.
Diseases that
impair movement, including arthritis, Parkinson's disease, and
their influence on patients' disease and coping mechanisms.
Polypharmacy and
dose-related issues in medical management of geriatric
populations.
Appropriate role of
extended care facilities and hospice.
In providing
patient-centered care, the student will demonstrate an understanding
of and sensitivity to gender, ethnic, and cultural issues at work in
the physician-patient encounter and in the patient's response to
disease, treatment, and wellness, with attention also to the
following:
Respect for the
individuality, values, goals, concerns, and rights of the patient
and patient's family regarding a wide range of issues, including
the following:
Sanctity of life
(brain death and vegetative states).
Reproductive
choice and infertility, safe sex counseling, contraception.
Sexual
orientation.
Religion, folk
remedies, income, education, and divorce.
Demonstration of
gender, ethnic, and cultural sensitivity through gender-specific,
ethnospecific, and culture specific activities and patient
encounters.
Anticipation of
female reproductive life cycle changes (puberty, first pregnancy,
menopause) including physiologic factors and provide education to
the patient to help maximize the acceptance of and adaptation to
these normal life stages.
Differences between
men and women in their disease presentations, risks, and responses
to therapies.
The student will demonstrate an
understanding of the psychosocial, economic, behavioral, and community
factors which influence a patient in his or her compliance and/or
response to disease and wellness. The student will use that
understanding to collect and incorporate appropriate psychosocial,
cultural, family, and community data into an appropriate patient care
plan by addressing the following specific issues:
Forces that can affect the process,
timing, and reasons for the patient to seek medical care.
Effect of family relationships (both
normal and abnormal) on health and illness.
Complex behavioral change and other
factors involved in patient compliance with medical plan.
Age-appropriate "normative" behavior
and serious psychiatric illness.
General medical illness in psychiatric
patients and the extent to which medical/surgical illness may
contribute to the psychiatric problem.
Role of education, economic
development, occupational environment, social institutions, and
recreation as important factors in the health status of communities
(particularly, rural communities) and the importance of addressing the
problems of individual patients and families by addressing community
problems.
Community resources and programs
(Public Health Department, Home Health Agency, Area Agency on Aging,
Department of Human Resources, etc.) that contribute to a community's
health care, unmet community health care needs and services and a plan
for the community to address those unmet needs, and the role of the
primary care physician as a leader and/or team player in addressing
community needs.
The student will demonstrate an
understanding of basic principles of economics and health care systems
and an appreciation of costs by doing the following:
Identifying and explaining
professional and ethical issues posed by costs and reimbursement on
primary care physicians, particularly under managed care systems.
Identifying and explaining the role of
the primary care physician as a coordinator of care, including
understanding the value of serving as a member of a health care team.
Identifying and explaining the role of
the primary care physician in understanding the availability, the
roles and effective use of both medical and non-medical consultation
and referral resources.
Identifying and explaining the role of
risk assessment, benefits calculation, and cost-of-treatment analyses
in cost-effective health care, quality assurance, and risk-management
decisions and using this information to formulate a rational plan of
investigation and management of patients with a variety of
diseases/conditions.
Identifying and explaining the impact
of various barriers to access to health care, including barriers
imposed by lack of insurance, third-party reimbursement systems, lack
of availability of high-level technology, under-compensated and
uncompensated care and rationing of services.
Identifying how health care reform may
affect the definition and role of the primary care provider.
Identify differences in the various
health care provider systems (e.g., PPO, HMO, fee-for-service;
capitated systems) and how they affect the physician and patient.
