Medical Knowledge and Clinical Care
Rural and Community Care Clerkship: This project will build on the strength of the current Family Medicine clinical clerkship. The new clinical curriculum will begin in April of academic year 2007-08. In this year long Phase III clinical curriculum all students will be required to complete a 4-week clinical clerkship in Rural and Community Care (with family physicians or selected rural general internists) and a 4-week Adult Ambulatory Care (AAC) clerkship (with either Denver-area family medicine or general internal medicine instructors) during an 8-week training block. Students identified by the Dean of Student Affairs with exceptional personal or educational needs (such as single parent, those with family illness etc.) will be placed in selected semi-rural practices within daily commuting distance of Denver.

Overall RCC Educational Framework: The content and process of this clinical training follows sound principles of adult education and is congruent with the principles of patient-centered and contextual care. The overall competencies of this upcoming clerkship are consistent with core values of care that will demonstrate that: a) providers in rural settings are skilled clinicians, b) they are a resource to the community, c) they consider their practice a population at risk and d) the patient-doctor relationship is considered paramount. Care has been taken to provide an experience that highlights these core values.

The RCC clerkship competencies that make up the educational focus are: 1) patient-centered assessment and management skills emphasizing 17 common symptoms/problems; 2) knowledge and application of recommended preventive health services; 3) effective communication skills; 4) knowledge of the effects of family, cultural and contextual issues on health and illness; 5) community assessment skills and awareness of local social and health resources and 6) demonstration of professional attributes including pursuit of adult learning methods to remedy situations where knowledge or skills are inadequate. In this new clerkship each student will be provided these learning objectives along with the teaching/learning methods and assessment strategies tied to each.

Current Educational Programming: The current Family Medicine clerkship has been an effective experience in attaining core competencies. In the current 2006-07 academic year to date students gave the clerkship a rating of 4.5 for its effectiveness at teaching patient-centered assessment and management of common problems, 4.4 for teaching the provision of preventive services, 4.2 for teaching the effect of culture and context on illness, 4.6 at teaching effective communication skills and 4.5 at teaching skills of adult/lifelong learning. (n=86, 5-point Likert scale: 1=not effective, 4=very effective, 5=highly effective). In 2006-07 to date students have evaluated the overall learning experience of the clerkship 4.6 (n=86) on a 5-point Likert scale. (1=Unsatisfactory, 4=Excellent, 5=Outstanding) Student evaluations of our curriculum and its effectiveness in teaching core competencies are excellent and are a credit to our clinical faculty. Since almost all instructors in the new RCC clerkship will be current faculty we expect the proposed project will be implemented in a similarly exemplary manner.

RCC Clerkship: Educational Strategies: The upcoming Rural and Community Care clerkship that begins in April 2007 will build on the strengths of the current mainly rural Family Medicine clerkship and will also conduct joint educational projects and evaluation with the 4-week Adult Ambulatory Care clerkship.

Students in both the 4-week Rural and Community Care and 4-week Adult Ambulatory Care clerkships will participate in a joint 4-hour orientation at the beginning of that contiguous 8-week block. Dr. Gaspar as Director of the FM-RCC clerkship will team with Dr. Kelly White of the Department of Internal Medicine who is Director of the AAC clerkship and other faculty to provide instruction at orientation. Dr. White already participates as a small group facilitator in the current FM clerkship orientation and this interdepartmental collaboration will continue in the new curriculum. Proposed topics presented to all students in this block 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)

Intense one on one clinical teaching will occur in these training sites. The clinical faculty will use the core symptom/problem list to guide teaching, but will also provide instruction related to any conditions commonly seen within their practices. In addition to this experience managing problems commonly seen in community practice students will also be required to complete other course work. During the course of their RCC clerkship students will participate in online discussion groups using Blackboard to reflect on unique aspects of rural health. Other assignments during their 4-week clerkship will include practice providing smoking cessation counseling, conducting depression screening and providing cardiovascular disease (CVD) risk screening and counseling patients on CVD risk reduction. In both 4-week clerkships of the block students will conduct a community assessment related to resources for CVD risk reduction in and report back to both the Rural and Community Care and Adult Ambulatory Care groups at an end of clerkship presentation. This will allow an opportunity to compare and contrast the urban to the rural experiences. Students will also be given a refresher mini-orientation to the Adult Ambulatory Care clerkship that follows.

Communication
During orientation students are instructed on the patient-centered clinical method. Students are evaluated on their ability to perform patient-centered encounters. This includes active listening skills, open-ended inquiry, identification of the patients’ agendae, determining the patients’ context and perspective of their illness and negotiating & communicating a management plan. Students and their clinical faculty will be instructed in using the SNAPPS format (with an extra “P” for patient perspective) to structure communication between instructors and their learners. Students will be required to practice small group presentations during their assigned PowerPoint presentation. Students are provided written instruction in their course syllabus on office notes and documentation.

Professionalism
Most clinical sites are sites in which students are placed involve working with one core clinical faculty. In addition most of these sites are in smaller communities where boundary issues may come into play. Most offices depend on a team of office staff, nurse practitioners and physician assistants. As noted above many of our sites have a large number of minority patients. This setting provides opportunity for students to demonstrate a commitment to carrying out individual professional responsibilities including ethical behavior, punctuality and honesty. In addition students will demonstrate how they work as a team with other providers and their ability to consider the diversity of their patients in order to provide exemplary care.

Systems Based Practice
A focus on Chronic Disease Management (CDM) and Cardiovascular Disease (CVD) risk assessment and intervention was introduced in the current Family Medicine clerkship. Case studies related to the elements of this care model were emphasized in small group sessions that occurred during orientation. This will be continued in both the upcoming Rural and Community Care clerkship and the Adult Ambulatory Care clerkships. Additional activities related to CDM will also be introduced by Dr. White in the Adult Ambulatory Care part of the 8-week block. Students are made aware of drug costs and will have a specific assignment where they are required to investigate the strengths and weaknesses of community based resources affecting cardiovascular disease and present it to their peers in both clerkships at the midpoint of the 8-week block

Self Directed and Lifelong Learning
Students are introduced to the Colorado Clinical Guidelines Collaborative (CCGC) materials and are required to utilize guidelines/flow sheets/algorithms in the care of patients at their practice site. The expectation is that these they will become familiar with and see the implementation of tools for practice based improvement. Students are evaluated by their individual clinical faculty on their orientation toward evidence-based practice, searching for and using point of care resources and self-reflection on their patient encounters.