Primary Care Clerkship Goals and Objectives

Adapted from:  Lawrence RS. The goals for medical education in the ambulatory setting. J Gen Intern Med 1988;3:S15-S25.

Attitudes

Acknowledge the patient's role as an active participant in his or her own care, through recognition of the patient's perceptions of his illness and his or her priorities for intervention *   ^4,2,6,8

• Recognize the potential of the physician-patient encounter itself as a therapeutic tool *  ^4,6,8   *see readings on "the scope of primary care internal medicine" and "the doctor- patient relationship"
• Accept uncertainty & learn to defer part of the evaluation to later visits when appropriate  ^5,2,3
• Appreciate the cost of health care and the need for parsimony in choosing diagnostic and treatment methods   ^5,6

Skills

• Refine patient communication skills, with particular emphasis on counseling skills for patient instruction, education, and motivation ^4,2,1,6,8,7
• Refine physical examination skills; in particular, the ambulatory setting provides a good opportunity to practice fundoscopy, the ENT exam, the musculoskeletal exam, the genital exam, and the rectal exam ^2,1,8
• Learn to conduct a focused evaluation, rather than a "complete H & P," where appropriate ^2,5,3,8
• Demonstrate the ability to present a patient's problem to other members of the health care team, focusing on the main complaint and pertinent positives and negatives from the history and physical examination.
• Apply principles of clinical decision-making in evaluation and test ordering, demonstrating understanding of the use of sensitivity, specificity, and predictive value ^5,1,3,7
• Use appropriate consultation and referral, and develop the ability to succinctly present a patient's problem to other members of the health care team ^3,4,5,7
• Use accurate but concise and legible means of documentation in the patient record and in other written communications   ^2,3,4,6,8
• Demonstrate the ability to counsel a patient on preventive health measures, including healthy diet, exercise, and immunizations.   

Knowledge

• Learn to manage common problems encountered primarily or exclusively in the ambulatory setting   ^1,5,3,7  e.g. hyperlipidemia, fatigue, common psychiatric problems in primary care, rashes, low back pain, upper respiratory infections, vaginitis, contraception
• Develop a broader perspective on diseases also commonly seen in the hospital  ^1,5,3,7 e.g. hypertension, diabetes, HIV infection
• Understand principles of health promotion and disease prevention  ^1,8,7 e.g. the periodic examination, immunization, smoking cessation, nutritional counseling
• Understand the basic principles of medical economics in the United States, particularly as they relate to payment for and access to ambulatory services. 

Learning Objectives

• Given a patient who smokes cigarettes, outline a smoking cessation counseling plan, based on the Agency for Health Care Policy and Research Clinical Practice Guideline for smoking cessation.
• Given a patient who smokes cigarettes, counsel the patient on use and side effects of Buproprion nicotine patch and nicotine gum.
• Describe the mechanism of action and side effects of a) HMG CoA Reductase inhibitors, b) bile acid resins, c) nicotinic acid, d) fibric acid derivatives, e) ezetimibe.  Describe each of their effects on the lipid profile.
• Describe the indications for TLC versus medications given a patient’s cholesterol valves and medical history.
• Describe criteria necessary for a diagnosis of hypertension.
• For each of the following classes of hypertensive medications, list side effects, indications, and demographic features (age, race, comorbid diseases) associated with greater therapeutic effectiveness: a) Beta blockers b) Thiazide diuretics c) ACE inhibitors d) Calcium channel blockers e) ARB’s.
• Define malignant hypertension
• Given an overweight patient with hypercholesterolemia and hypertension, list specific dietary measures which will help a) reduce weight b) lower cholesterol c) control hypertension.
• List the characteristics of a) migraine headache b) tension headache c) cluster headache. Outline acute therapy for each of these three types of headache.
• Given a patient with acute low back pain, compare and contrast the history and physical examination most consistent with a) lumbosacral strain b) sciatica.
• Describe therapy for lumbosacral strain.
• Given a patient with acute low back pain, list indications for obtaining a plain film of the lower back.  Define role for advanced imaging e.g. MRI.
• The student should be able to list the common diagnoses presenting as shoulder and knee pain to the primary care office and know which diseases present in certain patient           populations.
• The student should be able to perform an adequate shoulder and knee exam and know the names of the physical exam maneuvers used in each exam.
• List criteria for diagnosing diabetes mellitus.
• List the classes of oral hypoglycemic agents and describe their mechanism of action and associated side effects.
• Given a patient with adult onset diabetes mellitus, describe preventive measures for a) foot care b) immunizations c) diabetic nephropathy d) diabetic retinopathy e) diabetic neuropathy.
•  Given a patient with acute chest pain, compare and contrast history and physical examination characteristics associated with a) coronary ischemia b) musculoskeletal chest pain c) gastroesophageal reflux.
• Define somatization disorder. Outline an effective approach to the care of a patient with somatization disorder.
• List at least eight verbal or nonverbal clues that make a diagnosis of somatization more likely.
• List signs and symptoms of irritable bowel syndrome. 
• Outline a treatment plan for a patient with irritable bowel syndrome.
• Describe the clinical presentation of acute and chronic sinusitis and outline an appropriate treatment plan.
• Compare and contrast symptoms and physical exam findings consistent with a viral upper respiratory infection vs. streptococcal pharyngitis.
• Given a patient who complains of sore throat, describe indications for obtaining a rapid streptococcal screening test.
• The student should know the prevalence of upper respiratory infections presenting to the Primary Care Practitioner.
• The student should know how to diagnose and treat rhinosinusitis.
• The student should be able to explain the mechanism of antibiotic resistance in upper      respiratory infections.
• To understand antibiotic resistance mechanisms and the impact on primary care physicians.
• Given a patient with a urinary tract infection, define an "uncomplicated" urinary tract infection, and list examples of a "complicated" urinary tract infection.
• Describe a cost-effective approach to the diagnosis and treatment of an uncomplicated urinary tract infection.
• Compare and contrast signs and symptoms of viral, bacterial, and allergic conjunctivitis.
• Outline a treatment plan for a) viral b) bacterial c) allergic conjunctivitis.
• Know the signs and symptoms of hyperthyroidism and hypothyroidism.
• Know the etiologies of hyperthyroidism and hypothyroidism.
• Gain an understanding of the labs and studies used to diagnose thyroid disease.
• Know the work-up of a thyroid nodule.
• Understand how to treat hyperthyroidism and hypothyroidism.
• Know how to classify and define osteoporosis.
• Know the risk factors for developing osteoporosis.
• Know the screening guidelines for osteoporosis.
• Understand how to diagnose osteoporosis
• Understand the strategies for preventing and treating osteoporosis.
• Compare and contrast signs, symptoms, and simple lab findings of a) bacterial vaginosis b) candida vaginitis c) trichomonas vaginitis.
• Outline treatment for a) bacterial vaginosis b) candida vaginitis c) trichomonas vaginitis.
• Outline the immunization schedule for a well infant.
• List indications for a) influenza vaccine b) pneumococcal vaccine c) hepatitis B vaccine in the adult patient.
• List the U.S. Preventive Task Force Guidelines for screening for breast, prostate, cervical, and colon cancer.
• List the relative benefits for patients (example: years of life saved) associated with screening for breast, prostate, cervical, and colon cancer.
• Define test sensitivity, specificity, and positive and negative predictive value.
• Be able to list at least five (5) tactics used by Pharmaceutical companies to influence physician prescribing
• Describe what limitations the FDA has over controlling direct marketing to patients
• Describe the typical time course for rare, serious side-effects to surface after a drug is released on the market.