Orientation Didactics:
The block begins with a combined orientation for adult ambulatory care and rural and community care. The objectives, goals, and logistics of the courses are reviewed. There is also a case-based small group discussion and didactics. The topics include 1) General orientation to common problems in ambulatory care, 2) Depression screening and management, 3) An introduction to practice guidelines, 4) Using evidence to manage common ambulatory problems, 5) Basic dermatology and the skin cancer screening exam, 6) Clinical prevention and smoking cessation and 7) Basics of Chronic Disease Management. (CDM).

Cardiovascular disease risk assessment and counseling:
Students will be introduced to a cardiovascular risk assessment tool during the orientation to the block. They are then to complete cardiovascular risk assessment and counseling regarding risk modification on five different patients throughout the eight week block. We plan to incorporate the CV risk assessment tool into the patient’s medical record, and keep a registry of patients who have been counseled in the clinics so subsequent students can provide follow-up phone calls. The details of the patient registry and follow-up are currently being further defined. The CV risk assessment tools will be used in the assessment of community resources for the power point presentation.

Clinical encounters in primary care clinics:
Students will work in these clinics 70% of the time, and we feel they are very likely to experience firsthand all of the competencies during the 8 week block, based on data from the current family medicine clerkship. If not, they will be required to complete an on-line case regarding that competency.

Clinical encounters in subspecialty clinics:
Students will work in subspecialty clinics one half day per week for four weeks. Each student will be assigned to one subspecialty clinic for the entire four week block to enhance learning and continuity. The focus of the time in the clinic is management of chronic disease, utilization of system-based practice and improvements, and exposure to multidisciplinary care.

Power Point Presentation:
All students will be required to complete a power point presentation regarding their experience during the first four weeks of the block. Students will be given a clear outline with objectives for the presentation. Topics will include access to care, community resources, practice model, provider integration with community, and diseases managed. These will be presented to their peers in small groups on the fourth Friday of the block. The students will be divided into groups with equal representation from rural and non-rural settings. With the help of a faculty facilitator, they will compare these aspects of the practice of medicine in rural and non-rural settings.

Hospice Visit:
All students are required to complete a hospice visit. This is a full-day session including small group discussion and didactics. The first hour is an introduction to hospice including the role of hospice and relationship to palliative care, support available, requirements for hospice, pain management, and nutrition issues. The students then make a visit to a patient with a provider (chaplain, social worker, nurse) in a hospice setting. The students then meet again after the visit for a small group debriefing. Many issues are addressed including cultural concerns, pain control, use of fluids and artificial nutrition, etc. Students are given a pre-test and post-test to ensure the sessions’ objectives have been met.

Patient Centered Didactics:
All students on the adult ambulatory block will participate in a weekly half-day of didactics. Each session will begin with patient presentation(s) from the students pertinent to the topics to be covered that day. The didactics will focus on the pathophysiology, genetics, clinical manifestations, pharmacologic and lifestyle treatment of several chronic diseases including diabetes, asthma, COPD, and common geriatric syndromes. Instruction will occur in the form of interactive small groups, with predetermined objectives. On two of these half-day didactic sessions during the month, the students will review advanced clinical skills with a facilitator and patient in a small group after the case presentations and small group learning above. On the other two remaining half days (after the case presentation and small group learning), the students will present their project work. One project will be focused on health prevention. Students will research a question regarding health prevention based on a patient they have seen in clinic and present the results to their peers. The other project will require students to examine the components of chronic disease management models within the subspecialty and primary care clinics they have worked in. This will be limited to one disease, and students can discuss any aspect of the chronic care model they found to be particularly useful in the clinic. They will present the findings to their peers during the final half day of didactics.