Curriculum - Clerkship Overview

The clerkship consists of two phases completed over two academic years. In Phase 1 clerks will participate in a 2-week Introduction to the Clerkship Unit, followed by rotations in Internal Medicine (12 weeks), Family Medicine (6 weeks) Psychiatry (6 weeks), Surgical (9 weeks), Pediatrics (6 weeks), Obstetrics and Gynecology (6 weeks),  Emergency Medicine (3 weeks) and 2 weeks of elective time. There is a total of three weeks of vacation during Phase 1, two weeks at the end of Unit 1 and 1 week at the end of Unit 2. In Phase 2, there is a scheduled block that is designed for clerks to participate in 18-weeks of elective time. In addition, clerks will complete a 3-week rotation in Care of the Elderly (CoE). Vacation time and CaRMS interviewing time can be scheduled around the clinical rotations.

Objectives:

1. Conduct a clinical interview that includes effective verbal and nonverbal communication and results in the obtaining of complete, accurate data appropriate to any clinical situation. (SC1a, SC1c, SC2a, SC4a)
2. Conduct a clinical examination of patients of all ages and interpret the findings. (SC1a, SC2a)
3. Demonstrate clinical problem solving skills, including the ability to diagnose and initially manage with supervision, common acute and chronic illnesses. (SC2b, SC2d, SC3a-g; LLL1, LLL5; P3, P5; CC4)
4. Communicate effectively, orally and in writing, including recording in the patient chart, writing orders, presenting cases, prescribing, sending referrals, and summarizing patient care and recommendations. (SC1b-d, SC4a-b; P1-2)
5. Describe the indications for and methods used in common diagnostic investigations and interventional procedures and interpret the results. (SC2c-d; SC3c, SC4a-b; P2, P5)
6. Demonstrate competence in patient education regarding strategies for health promotion and disease and injury prevention. (SC1a-c, SC1f, SC3b, SC3d, SC3g, SC4a; CC1-3; P2, P4)
7. Demonstrate the attitudes and professional behaviors appropriate for clinical practice. (SC4a; P1-7)
8. Identify and use appropriate sources of information to support the delivery of patient care. (SC4c; LLL1, LLL3, LLL6)
9. Communicate and collaborate effectively as a member of an interprofessional team. (SC1c-d)

 

Unit/Rotation Descriptions and Objectives

• Introduction to the Clerkship
• Internal Medicine
• Family Medicine
• Psychiatry
• Surgical
• Emergency Medicine
• Obstetrics and Gynecology
• Pediatrics
• Electives
• Care of the Elderly
• Critical Review and Mastery (CRAM) with ACLS

Introduction to the Clerkship

This 2-week unit is designed to: refresh basic clinical and procedural skills learned in Med 1 and Med 2, introduce clerks to the hospital based clinical clerkship behaviours, procedures and processes, and provide opportunities to learn and practice clinical problem solving in various settings. 

Introduction to clerkship is the last time during Clerkship the class is all together.  All academic sessions are broadcast using Bridgit technology.

Objectives:

1. Describe the roles, responsibilities and expectations of 3rd year clerks. (2.7)
2. Demonstrate the ability to operate within the routines and logistics of inpatient wards and the functioning of ward teams. (2.4, 2.7)
3. Demonstrate proficiency in history taking, writing notes in SOAP format, writing progress reports, presentation, writing orders and dictating discharge summaries. (2.1)
4. Demonstrate beginning competence in basic procedural skills. (2.2, 2.3)
5. Demonstrate professional behaviours in relation to patients, peers, health professionals and colleagues. (2.7)
6. Demonstrate effective communication skills. (2.4)
7. Demonstrate the competencies required to provide care of the elderly. (2.2, 2.3, 2.6)

Internal Medicine

The Internal Medicine Unit incorporates the objectives of general internal medicine as well as the sub-specialties of internal medicine. Clerks will complete a 4-week rotation on the Medical Teaching Unit at the Halifax Infirmary, at the Clinical Teaching Unit in the Saint John Regional Hospital, or a combination of two weeks in the MTU and two weeks in the Emergency Department at the Halifax Infirmary (Unit Block A1); 4 weeks on a ward-based medicine rotation from a selected menu at the QEII-HSC (Unit Block A2); and 4 weeks which must be at least 50% ambulatory care on a medicine sub-specialty in Halifax or Saint John (Unit Block A3). As part of the learning experience clerks will take in-house call for Internal Medicine.

Objectives:

1. Conduct a clinical interview in adults with complex medical problems that results in the obtaining of complete and relevant patient history. (2.1)
2. Conduct a complete and relevant physical examination for adults with complex medical problems and be able to evaluate the results of this examination in the context of the patient history. (2.2)
3. Demonstrate clinical problem solving skills, including the ability to diagnose and initially manage with supervision, common acute and chronic medical conditions. (2.3)
4. Demonstrate an approach to the diagnosis and management of relatively uncommon medical conditions and appreciate how they might present in the clinical setting. (2.3)
5. Communicate effectively, orally and in writing, including recording in the patient chart, writing orders, presenting cases, prescribing, sending referrals, dictating letters and summarizing patient care and recommendations. (2.4)
6. Describe the indications for and methods used in common diagnostic and interventional tests including laboratory tests, x rays and electrocardiograms. Interpret the results of these tests within the context of the patient encounter, and their impact on diagnostic and therapeutic decision making. (2.5)
7. Demonstrate competence regarding strategies for health promotion and disease prevention in patients with complex medical conditions, including secondary prevention (i.e. delaying or preventing the progression of co-morbid disease). (2.6)
8. Demonstrate the attitudes and professional behaviors appropriate for clinical practice. (2.7)
9. Identify and use appropriate sources of information to support the delivery of patient care, including critical appraisal of the medical literature. (2.8)

Family Medicine

During this unit clerks will complete six weeks in Family Medicine.  During the 6-weeks in Family Medicine, clerks have the choice to complete either two, 3-week rotations or one, 6-week rotation.  Family Medicine rotations are completed throughout the Maritimes, with a limited number of rotations within the Halifax Metro area.  .  Students can select to work with physicians with particular interests such as Emergency Medicine, Obstetrics or Geriatric Medicine – please refer to Family Medicine Specialty Rotation Policy for further details.  A computerized match process will take place in the spring prior to the start of the clerkship year.  The rotation begins with a mandatory orientation and seminar day at the start of their 12 weeks block with Psychiatry. 

Objectives:

1. Recognize that the patient-physician relationship and continuity of care are central to the practice of Family Medicine. (2.4, 2.9)
2. Describe how illnesses present at an early undifferentiated stage in the Family Medicine environment when compared to the other clinical settings. (2.1, 2.2, 2.3)
3. Demonstrate effective communication skills in carrying out a patient-centered interview, exploring the patient’s illness experience, personal history and social context. (2.1)
4. Perform a physical examination, which is accurate and appropriate to the presenting problem and sensitive to patient comfort and interpret the findings. (2.2)
5. Describe the indications for, risks of and methods used in the common investigations, diagnostic and interventional procedures used for the common problems and presentations in a Family Medicine setting and interpret the results. (2.5)
6. Demonstrate clinical problem-solving skills, including the ability to diagnose and to initiate management (both non-pharmacological and pharmacological) with supervision, of the common problems and presentations in a Family Medicine setting. (2.3)
7. Communicate effectively, both orally and in writing, including documenting in patient records, making case presentations, writing prescriptions, writing referrals and in negotiating and summarizing the management plan with patients in a patient-centered manner. (2.4)
8. Demonstrate an understanding of common ethical issues in practice such as confidentiality, consent and patient autonomy. (2.7)
9. Recognize the importance of personal health on one’s ability to care for others. (2.7)
10. Introduce health promotion and disease prevention principles and activities appropriate to particular patient populations into the clinical encounter using evidence-based guidelines. (2.6, 2.8)
11. Demonstrate self-directed life-long learning and will use evidence-based resources to provide patient care. (2.8)
12. Identify and use or liaise with appropriate resources to support the delivery of patient care including inter-professional teams and community resources. (2.8)

Psychiatry

During the Psychiatry Unit, clerks will be exposed to a variety of psychiatric disorders. Clerks will complete a 6-week rotation, which will include inpatient, outpatient, community, short stay and consultation liaison psychiatry. Rotations will be completed in the Halifax Metro Area as well as other sites throughout the Maritimes, including Saint John and Kentville.

Objectives:

1. Conduct a comprehensive psychiatric evaluation that includes relevant collateral history, while demonstrating the capacity to build a therapeutic relationship with the patient and obtain complete and relevant information. (2.1, 2.2, 2.6)
   
2. Conduct and interpret a complete mental status examination, including the assessment of risk to self or others and cognition, as appropriate to the presentation of the patient. (2.1, 2.2)
   
3. Discuss the importance of co-morbidity of psychiatric and medical illness and evaluate and manage this with appropriate use of targeted physical examination, investigation and consultation. (2.3, 2.4, 2.9)
   
4. Integrate information obtained in the assessment to develop a working and differential diagnosis, using the DSM-IV, 5 axis model and terminology. Students should begin to describe the etiology of the diagnosis within a bio-psych-social framework relevant to the patient. (2.3, 2.6)
   
5. Develop and carry out (under supervision) a bio-psycho-social management plan that considers immediate, short term and long term treatment goals. (2.1, 2.2, 2.3, 2.6)
   
6. Discuss pharmacologic and non-pharmacologic strategies as potential treatment options for patients presenting with psychiatric illness including consideration of risk / benefit, indications, contraindications, common and serious side effects and interactions. (2.3, 2.6, 2.5, 2.8)
   
7. Communicate effectively, both orally and in writing, including documentation in patient charts, case presentations, writing orders and prescriptions, sending referrals and in providing education and negotiating a management plan with patients and their families. (2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8)
   
8. Work collaboratively within a multidisciplinary team, including accessing community resources and agencies to optimize the care of patients presenting with psychiatric illness and their families. (2.3, 2.4, 2.6, 2.8, 2.9)
   
9. Discuss the common clinical, ethical and legal issues in practice with specific emphasis on patient autonomy, confidentiality, involuntary admission and competency. (2.1, 2.2, 2.3, 2.5, 2.6, 2.7)
   
10. Demonstrate the attitudes and behaviors necessary to optimize the care of the patient presenting with psychiatric symptoms. Emphasis should be placed on recognition of the components of a therapeutic relationship and professional boundaries and on skills used by physicians to cope with stress and balancing personal and professional lives. (2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7)
    
11. Discuss the role of the social stigma of mental illness as a potential barrier to access to care and explore and manage their own preconceptions or reactions to patients with psychiatric symptoms. (2.4, 2.5, 2.6, 2.7, 2.8)
    
12. Demonstrate competence and commitment to lifelong learning that would include development of self-assessment skills and the use of evidence based resources to direct patient care. (2.3, 2.7, 2.8)

Surgical

The 9 weeks of the Surgical Unit are intended to provide the clerk with the broad principles of surgery and the basics in the individual surgical specialties as a foundation for postgraduate training. The clinical rotations are organized into 3 segments of 3-weeks each. All rotations are in Halifax, primarily at the QEII, but with some experiences at the IWK Health Centre.

All clerks will complete a mandatory 3-week General Surgery rotation. There are two 3-week selective rotations that can be chosen from the following nine specialties: Cardiac, Neurosurgery, Otolaryngology, Pediatric General Surgery, Plastic Surgery, Orthopedics, Thoracic Surgery, Vascular Surgery and Urology. Clerks will be scheduled for call duty, as these are important surgical experiences.

Objectives:

1. Describe the relevant anatomy and pathophysiology of common surgical problems including disorders involving the: (2.3)
   • Inner and outer ear, nasal passages, and oropharynx
   • Thyroid and parathyroid
   • Gastrointestinal tract (esophagus, stomach, small and large intestine)
   • Hepatobiliary system (liver and biliary tract)
   • Pancreas
   • Breast
   • Hernias
   • Cardiovascular system (heart and blood vessels)
   • Pulmonary system (lung and major airways)
   • Integumentary system
   • Neurologic system (brain, spinal cord, and peripheral nerves)
   • Musculoskeletal system (muscles, bones, joints)
   • Urogenital system (kidney, bladder and prostate)
2. Obtain an accurate, focused history from, and perform an appropriate physical examination of, patients presenting with surgical disorders of the aforementioned systems. (2.1, 2.2)
   
3. Request and interpret the results of appropriate laboratory and imaging investigations for these surgical conditions, while making efficient use of limited resources. (2.5)
   
4. Describe the management options and appropriate strategies for treatment of these surgical conditions. (2.3)
   
5. Manage, under supervision, peri-operative fluid administration and correct electrolyte imbalances. (2.3)
   
6. Describe the prevention and management of common post-operative complications including: wound infection or dehiscence, atelectasis, pneumonia, ileus, sepsis, organ failure, urinary retention, delirium and venous thromboembolism. (2.3)
   
7. Participate in the initial assessment and management of a polytraumatized patient, and describe the priorities of resuscitation, investigation and treatment. (2.3)
8. Describe requirements and procedures for obtaining informed consent for surgical procedures. (2.1, 2.4)
   
9. Collaborate and communicate effectively with other members of the Heathcare team to deliver optimal care to the surgical patient, while demonstrating professionalism and respect for others. (2.9)
   
10. Demonstrate competence in performing common procedures including venipuncture, intravenous access, nasogastric intubation, urinary catheterization, skin suturing, and knot tying. (2.3)

Emergency Medicine

All clerks entering Phase 1 of the clerkship will be required to complete a 3-week core rotation in Emergency Medicine. Clerks whose rotations are scheduled in the Halifax Regional Municipality will also be required to attend weekly mandatory teaching seminars and departmental grand rounds at the QEII HSC. For those clerks scheduled outside the HRM, they will be required to attend academics rounds as scheduled by the individual Emergency Departments.

Objectives:

1. Apply clinical knowledge to recognize and prioritize life- and limb-threatening illnesses and perform preliminary assessment ("sick" vs. "not sick") of undifferentiated emergency patients. (2.1, 2.2, 2.3)
   
2. Formulate a differential diagnosis for the presenting condition, listing the four most likely diagnoses and four "can't miss" diagnoses. (2.1, 2.3)
   
3. Formulate an initial investigation plan based on a tentative differential diagnosis. (2.3)
   
4. Describe and safely perform (independently) the following procedures, while minimizing patient risks and discomforts. (2.3)
   1. Phlebotomy
   2. Arterial blood gas
      
   3. Placement of an intravenous catheter
   4. Insertion of a Foley catheter
      
   5. Lead placement for ECG
   6. Open a minor procedure tray and don gloves using sterile technique
      
   7. Infiltrate a simple laceration with local anesthetic
   8. Repair of minor laceration with simple interrupted sutures
5. Use effective, non-judgmental and empathetic communication to establish a positive therapeutic relationship with patients and their families and effectively communicate discharge instructions to patients in an understandable fashion. (2.4)
   
6. Identify how risk factors in patients based on the broader determinants of health impact and contribute to the presentation of patients to the ED. (2.6)
7. Discuss how preventative care and health promotion is integrated into emergency care and practice these concepts in the care of patients (e.g. injury prevention). (2.6)
   
8. Relate the role of the ED in the health care system, the role of the EM Physicians within that system, the indications for consultation in the ED and the role of other health professionals in the ED. (2.8)
   
9. Develop and practice the professional behaviours and collaborative relationships required to work effectively in partnership with other professionals to provide patient care within the unique environment of a busy ED. (2.7, 2.9)
   
10. Describe and discuss the concept of triage. (2.1. 2.3, 2.8)
    
11. Describe the factors that determine if a patient can be safely discharged home including severity of acute medical illness, comorbidities, cognition and supports. (2.2, 2.3)

Obstetrics and Gynecology

The Obstetrics and Gynecology rotation will have 6 - 8 clerks located at the IWK Health Centre and 5-6 clerks will be at other sites. These include Kentville, Saint John and Charlottetown. All locations will be structured to provide a broad view of reproductive health as it pertains to women, covering the full spectrum from birth to climacteric. The aim of the rotation is to provide opportunity for good clinical exposure.

Objectives:

1. Describe the relevant normal anatomy and physiology, as well as the pathophysiology of the following: (2.2, 2.3)
   1. uterus
   2. ovaries
   3. fallopian tube
   4. cervix
   5. vagina
   6. vulva
   7. menstrual cycle
   8. labour
   9. pregnancy
   10. parturition
   11. lactation
   12. menopause
2. Conduct a thorough and accurate clinical interview appropriate to any obstetrical and gynecological clinical situation. (2.1)
3. Perform a complete physical examination of obstetrical and gynecological patients, and interpret the findings. (2.2)
4. Demonstrate clinical problem solving skills, including the ability to diagnose and initially manage with supervision, common obstetrical and gynecological conditions. (2.3)
5. Communicate effectively, orally and in writing, including recording in the patient chart, writing orders, presenting cases, prescribing, sending referrals, and summarizing patient care and recommendations in obstetrical and gynecological patients. (2.4)
6. Describe the indications for and interpretation of results of common diagnostic investigations and interventional procedures in obstetrics and gynecology. (2.5)
7. Demonstrate competence in patient education regarding strategies for health promotion and disease prevention in obstetrical and gynecological patients. (2.6)
8. Describe the requirements and procedure of obtaining informed consent for obstetrical and gynecologic surgical procedures. (2.4, 2.7)
9. Perform the following under supervision: vaginal delivery, placental delivery, pap smear and cervical swabs, urinary catheterization, intravenous access, skin suturing and knot tying, and examination of the newborn. (2.1, 2.2, 2.3)
10. Communicate and collaborate effectively with all members of the health care team in a professional and respectful manner, while caring for obstetrical and gynecological patients. (2.9)

Pediatrics

The 6-week rotation in Pediatrics will typically have 8 students located at the IWK Health Centre, 3 students in Saint John and a total of 1 - 3 students at one or more of the other sites in the Maritimes, which may include Charlottetown, Summerside, Fredericton, Antigonish, Sydney and Yarmouth. An academic half day is held on Wednesdays from 1230 to 5, during which tutorial sessions are conducted and broadcast to students at other sites using the Bridgit and Smartboard systems. Students also do a clinical case presentation and an adolescent interview during this rotation. At the Halifax site the experience is divided into 3-week ambulatory/ER and inpatient ward-based sections. The other sites offer an integrated experience over the 6 weeks.

Objectives:

1. Conduct a clinical interview in an age appropriate manner with a child or youth and/or accompanying adult that reflects knowledge of growth and development (physical, physiologic and psychosocial) and the content that is unique to the pediatric history. (2.1)
   
2. Conduct an age appropriate physical examination of infants, children, and adolescents and interpret the findings. (2.2)
   
3. Demonstrate clinical problem solving skills including the ability to diagnose and initially manage with supervision common acute and chronic illnesses of infants, children, and adolescents. (2.3)
   
4. Communicate effectively with parents and other care givers as well as with the child and adolescent throughout the course of care, incorporating knowledge of family centered care principles. (2.4)
   
5. Describe the influence of growth and physiologic maturation on the pharmacokinetics of medications as well as the influence of child behavior and psychomotor development on decision making in pediatric therapeutics. (2.3)
   
6. Demonstrate competence in basic fluid, electrolyte, and nutritional management of infants and children. (2.3)
   
7. Demonstrate competence in patient and family education regarding strategies for health promotion and injury prevention. (2.6)
   
8. Identify and use appropriate sources of information to support the delivery of pediatric patient care and of tools to support developmental surveillance. (2.8)
   
9. Communicate effectively, orally and in writing, with others members of the health care team, including recording in the patient chart, writing orders under supervision, presenting cases, sending referrals, and summarizing patient care and recommendations. (2.4, 2.9)

Electives

The objective of the program is to provide flexibility and opportunities in order to: gain experience in aspects of medicine not offered in the regular curriculum; study particular areas of the curriculum in greater depth; and explore career opportunities. The clinical elective period consists of two weeks in Phase 1 of Clerkship (Med 3) and 18 weeks in Phase 2 (Med 4).  The 2 weeks in Phase 1 is a single Pass/Fail unit, as is the 18 weeks in Phase 2. Students will be expected to identify objectives centered on the CanMeds competencies.

Objectives:

1. Demonstrate the skills of self-assessment, independent and life-long learning (2.8)
   
2. Practice the interdisciplinary management of patient care (2.9)
   
3. Participate in decision-making and education of patients and their families in an interdisciplinary team (2.6, 2.9)
   
4. Distinguish the differences in healthcare delivery in a smaller community versus tertiary care setting. (2.7)
   
5. Demonstrate an understanding of various aspects of medicine not offered in the scheduled curriculum (2.7)
   
6. Propose and achieve self-self-directed objectives in particular areas of the curriculum in greater depth specifically related to interprofessional collaboration and non-tertiary health care (eg community settings) (2.8)
   
7. Describe various potential career opportunities (2.7)

Care of the Elderly

Each student will complete 3 weeks in the Care of the Elderly unit. Although some rotations are located in the Capital Health region in Nova Scotia, the majority of students will be assigned to other sites in Nova Scotia, New Brunswick and Prince Edward Island.

Objectives:

1. Interview collateral historians, such as family members, to obtain a history of any cognitive impairment, and to determine the patient’s baseline and current level of function in activities of daily living. (2.1)
2. Obtain a detailed medication history that includes a list of all medications being taken, dosages, frequencies, indications, evidence of benefits, side effects, and assessment of adherence, and identify medications that are the most likely to cause adverse events in older individuals. (2.1, 2.3, 2.6, 2.8, 2.9)
3. Identify and document the components of a Comprehensive Geriatric Assessment. (2.1, 2.2, 2.4)
4. Construct a differential diagnosis and plan for investigation and management of a frail elderly patient who has fallen. (2.1, 2.2, 2.3, 2.5, 2.6, 2.9)
5. Diagnose dementia (perform a cognitive assessment, obtain a collateral history, and determine if the patient meets the criteria for dementia), describe the typical stages of Alzheimer’s disease, and develop initial plans for management. (2.1, 2.2, 2.3, 2.9)
6. Describe the process by which competency for personal care decision-making is determined. (2.1, 2.9)
7. List the causes and outline a plan for diagnosis and management for a frail elderly person with urinary incontinence. (2.1, 2.2, 2.3, 2.5)
8. Recognize that frail, elderly persons are at a higher risk of iatrogenic illness, and identify function, frailty, and life expectancy as factors that should influence the management plan.(2.3, 2.5)
9. Describe the ways in which common diseases such as diabetes, Parkinson’s disease, depression and heart disease differ in presentation and management for frail elderly persons. (2.3, 2.9)
10. Recognize the limitations of applying evidence obtained from clinical trials of younger, healthier persons to frail elderly persons. (2.3, 2.8)

Critical Review and Mastery (CRAM) with ACLS

This unit is scheduled as the last 3 weeks in fourth year. It is intended to help students prepare for their Medical Council of Canada Part 1 exams and their first year in residency. A focus will be on the basic science and clincial correlations of common clincal presentations. An Advanced Cardiac Life Support (ACLS) course is required for all PGY1 programs and will be offered to all 4th year students.

Objectives:

1. Identify gaps in knowledge and develop learning plans to fill the gaps. (2.3, 2.7, 2.8)
2. Review and consolidate all aspects of MD curriculum in preparation for the MCC exam. (2.3, 2.8)
3. Demonstrate skill in efficient study, preparation and review (2.7, 2.8)