MDC7200
MEDICINE CLERKSHIP

Duration: 8 Weeks Clerkship web pages: https://elearning.ufl.edu
DEPARTMENT OF MEDICINE CHAIR: Jamie Conti, MD

Gainesville Clerkship Director & Staff Information:

Ryan Nall, MD, Clerkship Director
Associate Professor, Division of General Internal Medicine, Department of Medicine
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John Merriman, MD, MPH, MS, Associate Clerkship Director
Assistant Professor, Division of Hospital Medicine, Department of Medicine
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Nancy Hendricks Parrish, Medicine Clerkship Coordinator
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Elisa Sottile, MD, Associate Clerkship Director – Jacksonville
Associate Professor, Division of General Internal Medicine, Jacksonville
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Kristyn Lewis, MD, Associate Clerkship Director – Jacksonville
Assistant Professor, Division of Pulmonary and Critical Care Medicine, Jacksonville
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Lauren Stemboroski, DO, Associate Clerkship Director – Jacksonville
Assistant Professor, Division of Gastroenterology, Jacksonville
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Lavetta Jones, Institutional Clerkship Administrator – Jacksonville
Jacksonville Office of Student Affairs
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CLERKSHIP INFORMATION

Clerkship Description
General Philosophy: Be caring and curious

The Medicine Clerkship is designed to be patient centered, which reflects internists’ devotion to patient care. You are expected to learn from each patient. Become the expert in the patient, know more about them than anyone else in the hospital, and the patient’s illness, read deeply about the disease process leading to your patient’s presentation. You should be involved in every aspect of your patients’ care from taking a history to writing orders to observing studies that they undergo (when possible). You are the member of the team who should know all the details about your patients’ support systems, medicines, lab data, etc. You should also be reading about their medical issues every night. There is something to be learned from every patient on the service. Therefore, you should participate in the rounds of all the patients and point out interesting findings on your patients to your fellow classmates.

The scope of Internal Medicine can be daunting thus the clerkship also is designed to promote self-directed, reflective learning habits that should serve you well throughout your career. Therefore, you are expected to take the initiative in all aspects of your learning. This includes actively seeking feedback, participating in discussions, sharing your knowledge with others, and of course, spending time with your patients.

The Medicine Clerkship is divided into three blocks. One 4-week general internal medicine inpatient experience, a 2-week general internal medicine inpatient experience, and a 2-week subspecialty consult service experience. It is impossible to teach you all of internal medicine in eight weeks, but we will do our best to teach you the core topics that we think every physician should know. We will also emphasize the clinical reasoning process and utilization of educational resources to encourage your own self-study.

Small Group and Clerkship Seminar Leaders – Gainesville

• Dr. Diana Barb – Thyroid Disorders
• Dr. Gabriel Bonnell – Altered Mental Status
• Dr. Beverly Dede – Wellness Rounds Dr. Jennifer Duff – Cancer
• Dr. Heather Harrell – HARVEY Part 2
• Dr. Robert Hollander – Acid/Base Disorders/Humanism
• Dr. Sheri Kittelson – Ethics of Dying
• Dr. John Merriman – Doc in the Box
• Dr. Jay Lynch – Doc in the Box
• Dr. Michael Massoomi – ACS
• Dr. Marjorie Montanez – Wiscovich – Cutaneous Manifestations of Systemic Disease
• Dr. Ryan Nall – HARVEY Part 1/Q&A/Doc in the Box/Oral Presentations/Shelf Review
• Dr. Shiyi Pang – Anemia
• Dr. Nayelah Sultan – High Yield Medicine
• Dr. David Winchester – EKG Part 1&2

Small Group and Clerkship Seminar Leaders – Jacksonville

• Dr. Pramod Reddy – Acid/Base Disorder
• Dr. Carlos Palacio – Anemia/Doc in the Box
• Dr. Jeff House – EKG Part 1&2
• Dr. Lauren Stemboroski – High Yield Medicine/Doc in the Box
• Dr. Shannon LaBoy – Altered Mental Status Review
• Dr. Walter Quan – Cancer Dr. Elisa Sottile – Humanism/Doc in the Box
• Dr. Rafik Jacob – Cutaneous Manifestations of Systemic Disease
• Dr. Jose Rivas and Dr. Pankaj Mathur – ACS

Learning Objectives:

Goal 1: Professionalism – Caring, Character, and Clinical Competence
Unprofessional behavior will result in a lowering of your grade and potentially an unsatisfactory evaluation for the entire clerkship with appearance before the Academic Status Committee.

Objectives:

1. Treat all patients, staff, and colleagues with respect. This includes the following:
   • Displaying good manners
   • Displaying sensitivity to cultural differences
   • Adhering to the dress code
   • Avoiding confrontations
2. Display honesty which includes the following:
   • Showing discernment while avoiding deception when communicating with patients and their families
   • Not passing others’ work off as your own
   • Adhering to the Honor Code
3. Demonstrate caring towards patients and their families, colleagues, faculty, and all members of the health care team (including staff), which includes the following:
   • Effectively communicating empathy
   • Putting patients’ needs above your own (altruism)
4. Demonstrate a good work ethic, which includes the following:
   • Showing intellectual curiosity
   • Accepting responsibility for your patients
   • Being prepared and on-time
   • Being accountable
   • Being dependable
   • Reliable attendance and participation (refer to College of Medicine Policies)
   • 90% attendance in clerkship seminars, workshops, and lectures
5. Strive for excellence
   • Actively seek to help
   • Actively seek to broaden education and experience beyond clerkship requirements
   • Avoid complaining
6. Accurately self-assess (this overlaps with PBLI and also will be addressed under that competency)
   • Actively seek and apply feedback
   • Give feedback (including filling out course and teaching evaluations in a timely manner)
   • Convey humility
     

Evaluation: House staff and faculty will observe students interactions with the medical team, other health professionals, and with patients and their families. Performance in this competency will be evaluated through clinical evaluations.

Your professionalism will also be assessed using the Professionalism Mini Evaluation Exercise (P-MEX) instrument. This tool is used to assess professionalism in clinical training. The evaluator rates the trainee on 24 different directly observable items of medical professionalism over four different skill areas: doctor-patient relationship skills, reflective skills, time management, and interprofessional relationship skills.

You will be required to obtain the following over the course of the clerkship:

• 2 to be completed be a faculty or resident with whom you closely work. You will solicit these yourself, which will be aimed at providing real-time formative assessment
• IM/OB/Peds/Surg 1 peer evaluation, which the clerkship administrative team will assign to a peer with whom you work closely on one of your core inpatient teams
• Up to 1 from the clerkship coordinator. The administrative team will assign these such that you receive two over the course of the year.

Performance on the PMEX will not directly be calculated into grade on this clerkship but will contribute to the pilot of programmatic assessment of professionalism across third year. Comments provided on the PMEX will be provided to you in your summative assessments. Any professionalism concerns will be addressed in standard fashion as outlined in the syllabus.

Goal 2: Patient Care – Evaluate and manage patients hospitalized with acute illness.

• EPA 1: Gather a history and perform a physical examination
• EPA 3: Recommend and interpret common diagnostic and screening tests
• EPA 2: Prioritize a differential diagnosis following a clinical encounter
• EPA 4: Enter and discuss orders and prescriptions
• (EPA= Entrustable Professional Activity)

Objectives:

1. Obtain and record a patient’s history in a logical, organized, and thorough manner.
   
   Learning activity: Interview, examine, and write a complete H&P for each new patient assigned to you (even if there is already a note). You must admit a minimum of two new patients per week, minimum of 16 patients per rotation.
   
   Evaluation: Any H&P can be evaluated by your peers, and you may revise your H&P based on peer feedback. You must give at least one H&P per month (2 over 8 weeks) to your IM coach to make sure you are on the right track. You may not revise and turn in notes based on faculty or resident feedback but instead should apply this feedback to your next write up. You will submit one write-up weeks 2, 4, 6, 8. Your top 3 highest scored write-ups will count for your final grade. These will be evaluated by the Clerkship Directors as part of your grade.
   
2. Perform and record a complete physical examination in a logical, organized, and thorough manner for new patients and an appropriately focused physical examination for follow up patients.
   
3. Be able to recognize normal from abnormal physical findings and identify the following abnormalities:
   • Orthostatic Vital Signs
   • Petechiae
   • Jaundice
   • Ascites
   • Edema
   • S3
   • Elevated JVP
   • Heart murmur
   • Irregularly irregular pulse
   • Goiter/abnormal thyroid exam
   • Crackles
   • Dullness to percussion
     
     Learning Activity: Each student should be observed performing a complete physical examination. Simulation activities will review abnormal heart sounds and thyroid. Physical finding rounds will be offered to supplement students’ skills. IM coaches are available to observe parts of the physical exam if your teams have trouble finding time.
     
     Evaluation: House staff and faculty will observe students performing histories and physical examinations in the course of patient care and these observations will inform the summative evaluation. Four mini-cex forms focused on both history(2) and physical exam (2) must be completed and uploaded on canvas during the clerkship. Students MUST be signed off on an abnormal physical finding card for the above abnormal findings. This card should be scanned/photographed and uploaded on canvas.
4. Interpret important supplemental information, including CBC, serum chemistries, INR, BNP, Iron Studies, Blood culture, pleural/peritoneal chemistries, ABG, coagulation studies, urinalysis, chest x-ray, CT chest, CT Head and ECG.
   
   Learning activity: Students will have ample opportunity to review their patients’ lab data, ecgs and imaging. Students will be provided an ECG teaching packet supplemented by two small group activities. There is a dedicated conference to review chest imaging. Lab results, ECGs, and radiology images will be reviewed with the team on rounds.
   
   Evaluation: Students’ understanding of these tests will be assessed in small group discussions on rounds, H&Ps, and on the NBME subject exam.
5. Use clinical reasoning to synthesize data into a prioritized differential diagnosis that clearly states a working diagnosis, to guide initial diagnostic evaluation and disease management.
   Learning activity: This will be discussed on daily rounds with the teams, practiced using the online, interactive Aquifer Internal Medicine cases, and the clinical reasoning process is explicitly taught in the twice weekly “Doc in the Box” small group sessions. Students may select the cases that best fit their learning needs but should pay close attention to the summary statement feature in each case.
   
   Evaluation: This is assessed by the teams on daily round interactions and review of progress notes. This is also assessed with the H&Ps. Students select 4 of the (at least) 16 H&Ps that they complete during the clerkship that best demonstrate their clinical reasoning and medical decision-making skills to submit for evaluation weeks 2, 4, 6, 8. These 4 H&Ps are assessed by the clerkship directors and the top 3 scores are used as part of your final grade.

Goal 3: Medical Knowledge – Demonstrate understanding of the clinical presentation, basic pathophysiology, evaluation and management of diseases frequently encountered in an inpatient medicine setting.

Objectives:

Review the pathophysiology and be able to recognize and initiate evaluation and management plans for the following disease states/clinical presentations that are recommended in the national Clerkship Directors of Internal Medicine Core Curriculum. This can be used as a study guide.

• Abdominal pain (AQUIFER INTERNAL MEDICINE cases 9,12)
• Acute mental status alteration (AQUIFER INTERNAL MEDICINE cases 25, 26)
• Acute myocardial infarction/acute coronary syndrome (AQUIFER INTERNAL MEDICINE case 1)
• Acute renal failure (AQUIFER INTERNAL MEDICINE case 33)
• Anemia (AQUIFER INTERNAL MEDICINE case 19)
• Arrhythmia (AQUIFER INTERNAL MEDICINE case 3)
• Asthma
• Anxiety
• Back pain (AQUIFER INTERNAL MEDICINE cases 27, 34)
• Cancer (AQUIFER INTERNAL MEDICINE cases 17, 27)
• Cardiovascular disease (AQUIFER INTERNAL MEDICINE cases 2, 4)
• Chest pain (AQUIFER INTERNAL MEDICINE case 2)
• Chronic kidney disease (AQUIFER INTERNAL MEDICINE case 23)
• Chronic obstructive lung disease (AQUIFER INTERNAL MEDICINE case 28)
• Common geriatric issues (dementia, incontinence, falls, osteoporosis) (AQUIFER INTERNAL MEDICINE cases 13, 18)
• Congestive Heart Failure (Aquifer IM Case 4)
• Cough (AQUIFER INTERNAL MEDICINE) case 22)
• Depression (AQUIFER INTERNAL MEDICINE case 5)
• Diabetes Mellitus (AQUIFER INTERNAL MEDICINE cases 7, 8)
• Dizziness (AQUIFER INTERNAL MEDICINE cases 3, 7)
• Dyslipidemia (AQUIFER INTERNAL MEDICINE case 16)
• Dyspepsia/ Peptic ulcer disease (AQUIFER INTERNAL MEDICINE case 10)
• Dysuria/urinary tract infections (AQUIFER INTERNAL MEDICINE cases 14, 21)
• Fever (AQUIFER INTERNAL MEDICINE cases 27, 29, 35)
• Electrolyte Disorders (AQUIFER INTERNAL MEDICINE cases 7, 25, 26, 27)
• Gastrointestinal bleeding (AQUIFER INTERNAL MEDICINE cases 10, 21)
• Headache (AQUIFER INTERNAL MEDICINE case 24)
• Heart failure/valvular heart disease (AQUIFER INTERNAL MEDICINE case 3)
• HIV (AQUIFER INTERNAL MEDICINE case 20)
• Hypertension (AQUIFER INTERNAL MEDICINE case 6)
• Joint pain (AQUIFER INTERNAL MEDICINE cases 31, 32)
• Liver failure (AQUIFER INTERNAL MEDICINE cases 11, 36)
• Lower respiratory tract infection (AQUIFER INTERNAL MEDICINE case 22)
• Lymphadenopathy (AQUIFER INTERNAL MEDICINE case 20, 35)
• Meningitis (AQUIFER INTERNAL MEDICINE case 24)
• Nosocomial infection (AQUIFER INTERNAL MEDICINE case 24)
• Obesity (AQUIFER INTERNAL MEDICINE case 16)
• Palliative care principles (AQUIFER INTERNAL MEDICINE case 27)
• Pancreatitis (AQUIFER INTERNAL MEDICINE case 9)
• Rash (AQUIFER INTERNAL MEDICINE case 17)
• Rheumatologic disorders (RA, spondyloarthropathies, SLE, systemic sclerosis, Sjogren syndrome, vasculitides, polymyositis, dermatomyositis) (AQUIFER INTERNAL MEDICINE case 32)
• Sepsis (AQUIFER INTERNAL MEDICINE cases 21, 24)
• Shortness of breath (AQUIFER INTERNAL MEDICINE cases 4, 22, 28)
• Substance abuse (AQUIFER INTERNAL MEDICINE cases 9,15, 26)
• Pre-Syncope or Syncope (AQUIFER INTERNAL MEDICINE case 3, 7)
• Thromboembolic disease (AQUIFER INTERNAL MEDICINE case 30)
• Thyroid disorders

Learning activities: Many of these topics are covered in the interactive “Doc in the Box” teaching sessions. Expert faculty will meet with students for case-based sessions which reinforce many of the concepts taught in the AQUIFER INTERNAL MEDICINE cases and, of course, students will actively care for patients with many of these medical problems. The above list also is intended to help guide students’ reading. Students are strongly encouraged to learn about all of their patients’ past medical problems in addition to the acute problems to further enhance their medical knowledge.

Requirements: Students must provide evidence of patient exposure OR completion of the Aquifer Internal Medicine case for the 12 core presentations that are in boldface above by using the patient log in New Innovations. AQUIFER INTERNAL MEDICINE cases may substitute for an actual patient when students do not have the opportunity to care for a patient with one of the required presentations. Students are responsible for keeping track of their logs. The patient logs are a College of Medicine graduation requirement. Each student will receive a summary of their patient log at the end of the clerkship. Incomplete logs will result in a “H” hold on the grade until the appropriate AQUIFER INTERNAL MEDICINE case(s) is(are) completed. It may also result in a subtraction of up to 1 point from the PBLI competency.

Evaluation: National Board of Medical Examiners subject exam (multiple choice) in internal medicine.

Goal 4: Communication and Interpersonal Skills – Establish effective communication to identify and respond to each patient’s emotional needs and their personal desires regarding their medical treatment. Communicate effectively with team members to enhance team dynamics and patient care.

• EPA 6: Provide an oral presentation of a clinical encounter
• EPA 5: Document a clinical encounter in the patient record

Objectives:

• Establish effective rapport with patients and their families.
• Speak clearly to patients and their families using language they can understand (avoid medical jargon).
• Convey empathy to patients from a variety of cultures and backgrounds.
• Keep team informed of patients’ progress and communicate with other healthcare members outside the team as needed.

Learning activities: Students will speak to patients and their families daily. Students will observe, and when appropriate, actively participate in more advanced communications with patients and their families such as breaking bad news, obtaining informed consent, obtaining advanced directives, and explaining new diagnoses or treatments. Feedback will be provided by the students inpatient teaching team and patients.

Evaluation: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument. Students have the option (not required) to have patients and families evaluate their communication skills using a structured patient evaluation questionnaire provided by the clerkship.

• Orally present a patient’s history, physical examination, lab data, assessment and plan clearly, concisely, yet with relevant details.
  
  Learning activity: This is practiced on daily rounds with the whole team present. More comprehensive presentations are typically performed with the attending or resident. One-on-one feedback is given at that time. Dr. Nall will lead optional small group practice sessions that you can sign up for on the sign-up sheet posted on the door of the clerkship office. IM coaches and peers are another venue to practice this difficult skill.
  
  Evaluation: Attendings and residents who directly observe this will provide formative and summative feedback.
  
• Write cogent, clear progress notes that are up to date and document working diagnoses and status of diagnostic evaluation and therapeutic plans.
  
  Learning activity: Students practice this by writing daily progress notes on all their patients. Daily progress notes are a clerkship requirement. These should be in the EMR in a timely manner (ideally before noon conference). EPIC templates which automatically import data are not allowed. Templates which provide the general framework for your note and import vital signs and current medications are acceptable.
  
  Evaluation: Progress notes are primarily evaluated by the housestaff. To ensure adequate feedback, students should ask residents and faculty if they would prefer to have notes from the EMR printed and handed to them. Students also have the option of reviewing them with their IM coach.

Goal 5: Practice-based Learning – Develop skills that foster life-long learning habits

• EPA 7: Form clinical questions and retrieve evidence to advance patient care

Objectives:

• Based on self-assessment and the clerkship objectives, create a set of personal SMART goals for the clerkship and reflect on your progress, modifying as necessary. These SMART goals should be brought to the mid-point clerkship meeting.
• Actively seek feedback and perform reflection and self-assessment routinely.
• Apply EBM skills in real time to patient care

Learning activities: Students will develop goals with guidance from their IM coach and meet either individually or with their “teamlet” to review their progress and revise their goals as needed. Students will reflect on their progress. Students must obtain formative feedback, using the formative feedback form, from attendings and housestaff with whom they worked the most. This can be done individually or with several team members at once (e.g. residents and faculty).

Assessment methods: Formative and summative feedback will be obtained from the ward team using a structured evaluation instrument.

Systems-based Practice – Work effectively as part of a team. Develop an understanding of resources needed by patients and the resources and limitations of the current health care system.

• EPA 9: Collaborate as a member of an interprofessional team
• EPA 13: Identify system failures and contribute to a culture of safety and improvement

1. Work as an effective member of the patient care team, demonstrating reliability, initiative, organization, and helpfulness.
2. Gain an understanding of interprofessional coordination and planning required when transitioning patients from the inpatient to outpatient setting.
3. Act as your patients’ advocate.
4. Practice high value care

Learning activities: Work with housestaff and care managers one-on-one to help recognize and meet patients’ specific needs for interprofessional services or other support both in the hospital and after discharge. Discuss cases with consultants and the non-physician members of the health care team when they are involved. Every student must complete the Aquifer High Value Care modules 1 and 5. These are different from the Internal Medicine Cases.

Assessment methods: Daily participation on work rounds, progress notes, and discharge planning paperwork will be assessed by the attending physician and housestaff and feedback given at that time and through a structured evaluation instrument. A log and reflection on post discharge follow-ups will be submitted at the end of the clerkship. A reflection on your review of a patient’s bill will be submitted at the end of the clerkship.

On Demand Evaluations

Clerkships now offer on-demand evaluations in New Innovations, giving you the ability to request evaluations directly from the faculty and residents you work with. You’ll be able to choose who evaluates you, generate the evaluation request yourself, and New Innovations will immediately send them a prompt to complete it. (On the faculty/resident side, the evaluation form will look the same—it will just arrive sooner.)

This system is designed to help you receive more timely and meaningful feedback, since you can request an evaluation shortly after working with someone, rather than relying on evaluations submitted at the end of the rotation, often weeks later.
Each clerkship will provide guidance on how many evaluations you are expected to initiate and when you should submit these requests. Clerkships may also continue to initiate evaluations on your behalf when needed.

If you have questions or concerns, please reach out to your course administrator. For technical issues with New Innovations evaluations, contact Michael Bruce.

For the Medicine Clerkship: You can request a clinical evaluation from anyone you feel can evaluate your clinical performance. If you work with a resident, intern, or attending 5 days or more you MUST request a clinical evaluation. If there is a reason you aren’t requesting a clinical evaluation from someone with 5 days or more contact, the rationale must be communicated to the clerkship administrator through the Canvas assignment. Each two weeks you will list everyone you requested an evaluation from.

Board of Governors Attestation Regarding Clerkship Instructional Materials

Instructional materials for this course consist of materials reviewed, selected, and assigned by the instructor(s). The instructor(s) is only responsible for these instructional materials. Based on self-assessment of learning needs, students may identify other credible resources to augment the identification, analysis, and synthesis of relevant information.

Recommended Textbooks and Educational Resources and Computer

(Day to day reading)

• First Exposure Internal Medicine, Hospital Medicine, Charles H. Griffith, III, Andrew R. Hoellein, Christopher A. Feddock, Heather E. Harrell, 2007, 1st Edition, ISBN: 0071459014
• Symptom to Diagnosis, Scott D. C. Stern, Adam S. Cifu, Diane Altkorn, 202, 4th Edition, ISBN: 9781260121117
• Aquifer Internal Medicine

(In-depth Reading)

• Harrison’s Principles of Internal Medicine, Joseph Loscalzo, Anthony Fauci, Dennis Kasper, Stephen Hauser, Dan Longo, J. Larry Jameson, 2022, 21st Edition, 9781264268467

Computer Requirement

Personal Laptops
Personal laptops can be utilized in clinical spaces and should meet the computer requirements laid out by the College of Medicine (https://osa.med.ufl.edu/support/policies-procedures/computer-requirement/). While desktops are typically available on all clinical rotation sites it is recommended that you bring a personal laptop in case a desktop is not available. Laptops can be safely stored at UF Health GNV in lockers in the student lounge (North Tower Room 4207), lockers in the team rooms at the VA, and lockers in the Dr. Haley Medical Student Lounge at UF Health Jax (4th Floor Clinical Center).

ASSESSMENT

Instructions for Formal Self-Assessment and Formative Feedback

Whether you recognize it or not, you will receive feedback many times a day during clinical rotations. Sometimes it is obvious such as being corrected on physical exam technique or being told your progress note was helpful. Other times it may be less obvious, perhaps even nonverbal, such as a smile of encouragement or having your rounds presentation interrupted and cut off. We know a key aspect of effective feedback is that it should be specific and linked to a behavior. We like to be positive and encouraging to you on this clerkship so you will frequently be told you are doing a “good job” or “great work”. While this certainly can improve your spirits, it is not very helpful feedback if you don’t know what you did to earn the compliment. One simple thing you can do is to ask for clarity on what specific behavior was being complimented so you will know how to reproduce it.

Both you and your attending should complete a Formative Evaluation Form that is exactly the same as the form used for your summative evaluation at the end of each 4 weeks. Around the mid-point of each month (or of the time you spend with your attending), you are to fill out an evaluation form for yourself. At the same time, you should provide your attending a form to complete. (Forms can be printed from this site.) Next, you will arrange a time to meet and compare your evaluations.

On some services, you will have more than one attending during the month. You are encouraged to do this formative feedback with each attending. Interns and residents also evaluate you and see different aspects of your performance. Thus, we strongly encourage you to seek formal formative feedback from them as well.

Many attendings will initiate this feedback. But, it is your primary responsibility to make sure the formative feedback sessions occur.

A minimum of two submissions are required (one per month). You are required to summarize in a few sentences the key points of the feedback session that includes:

1. Strengths
2. Areas to work on
3. How well your self-assessment agreed with your attending’s assessment (and if there was a discrepancy between the two, why you think that was)
4. Your next steps for continued growth.

If you are unable to identify #1,2, and 4 above, then this should prompt you to seek clarification and/or further direction from the person who gave you feedback.

Mid-Rotation Feedback Meeting with Clerkship Director
Students will be scheduled by the Clerkship Coordinator to meet with one of the Clerkship Directors for mid-rotation feedback. Students will complete the Mid-Rotation Self-Assessment Form and bring the completed form to the meeting. The Action Plan section will be completed during the meeting. The completed form will be uploaded to Canvas after the meeting.

Professionalism Mini Evaluation Exercise (P-MEX)
The Professionalism Mini Evaluation Exercise (P-MEX) is an instrument used to assess professionalism in clinical training. The evaluator rates the trainee on 24 different directly observable items of medical professionalism over four different skill areas: doctor-patient relationship skills, reflective skills, time management, and interprofessional relationship skills.
You will be required to obtain the following over the course of the rotation:

• Two (2) to be completed by a faculty or resident with whom you closely work. You will solicit these on-demand through new innovation or completion of a paper copy, which will be aimed at providing real-time formative assessment
• IM/OB/Peds/Surg 1 peer evaluation, which the clerkship administrative team will assign to a peer with whom you work closely on one of your core inpatient teams
• Up to 1 from the clerkship coordinator. The administrative team will assign these such that you receive two over the course of the year.

Performance on the PMEX will not directly be calculated into grade on this clerkship but will contribute to the pilot of programmatic assessment of professionalism across third year. Comments provided on the PMEX will be provided to you in your summative assessments. Any professionalism concerns will be addressed in standard fashion as outlined in the syllabus.

How Grades are Determined

During this clerkship you will be evaluated in all of the six core competencies of the college of medicine. As you know, the competencies are highly interrelated and therefore the way we divide some of the behaviors is somewhat arbitrary. When viewed as a whole, the six competencies do cover all the major qualities we want to assess in your development as a physician. There are multiple ways we can assess your performance on this clerkship.

On the medicine clerkship we assess you using a standard MCQ NBME subject exam, evaluations by your teams (faculty, residents, and interns), and evaluations of 4 write-ups. Each of these methods of assessment works well for some competencies and not as well for others. The following is a breakdown by competency of how the evaluations are weighted.

Professionalism (S/U): We operate under the assumption you are professional. This is best confirmed by your teams, so the ward evaluations are the primary method of assessment. However, the way you interact with staff, your IM coach and teamlet, and your ability to follow directions also are considered. We use the 4 questions common across all clerkships assessing respect, honesty, work ethic, and striving for excellence. These 4 items were designed to pick up concerns rather than discriminate degrees of professionalism. If we see a pattern of concerns this could lower your evaluation by half a letter grade. If something very egregious is reported and confirmed (e.g. cheating) this could lead to a “needs remediation” in professionalism and not passing the clerkship. Attendance at seminars, workshops, and lectures will also be considered as part of this competency. A minimum of 90% attendance is required. Very serious professionalism concerns will be reported to the Academic Status Committee.

Patient Care (35%): 20% is from ward evaluations using the 9-point scale, 15% is from the 3 highest scored H&Ps out of the 4 H&Ps submitted. Please note patient write-ups are looked at very closely, particularly in terms of how you prioritize and organize problems into a problem representation, develop a differential diagnosis and subsequent working diagnosis. (Doc-in-the-Box sessions can really help you learn to do this if it is a weak area.) We evaluate the 4 write-ups you select as representing your best work using the IDEA evaluation tool that you used for peer feedback.

Medical Knowledge (25%): Fund of knowledge is assessed by the NBME subject exam (20%) and evaluations by your team (5%). The subject exam scores are converted to the 9-point scale using the following conversion which is based on national percentiles and updated annually. If you score 84 (90th percentile) or higher you will receive the max score of 9 for the shelf exam. There is not a minimum exam pass score for the clerkship. However, students who score below the 10th percentile nationally (63) need to meet with the clerkship director to discuss whether a test taking remediation plan should be developed to promote improved performance on subsequent NBME exams including Step 2 CK.

Communication (20%): This relates to your interaction with patients and your ability to communicate effectively with other team members in the form of oral presentations and daily progress notes. It is evaluated by your teams using the 9-point scale. You also can ask patients to directly evaluate you. This is optional (evaluation forms in the clerkship office). Eight or more patient evaluations will be averaged in with your team evaluations of your patient communication skills (10% of this competency). Specifically, if you have at least 8 patient evaluations with an average rating of 4.7 or higher, we will treat that as a score of 9 for 50% of your patient communication skills score and the team evaluation will be the other 50% of that score. If the patient evaluation average is 4.2-4.6, we will average in an 8 (only if this helps you). We have never had a student’s patient evaluation average lower than this and would not factor it into your score. Team evaluations of your notes (5%) and oral presentations (5%) make up 10% of this competency.

Practiced-based Learning (10%): This is evaluated by your teams using the 9-point scale. You will also review the required SMART goals during your mid clerkship feedback session and summaries of formative feedback will be submitted at the end of the clerkship.

System-based Practice (10%): This is evaluated by your ward team as it related to your ability to function as part of a team using the 9-point scale. Additionally, you are required to complete HVC modules 1 and 5.

The final grade is determined by generating a score from 1-9 for each competency as described above. These scores are then weighted according to the percent weights noted above for each competency. Those weighted scores are added together to get a final numeric score that is assigned a grade using a scale which will be determined for 2025-2026. The grade cut offs for 2025-2026 are listed below. Your final performance will globally be reviewed by a grade committee.

Grade Grievance Policy

Medical students may appeal a grade or evaluation. The process is as follows:

1. The student submits his/her written concern(s) about a grade or evaluation and arranges a meeting to discuss the concern(s) with the relevant clerkship or course director within one month of the posting of that grade.
   If the student is not satisfied with the outcome:
2. The student may submit their written explanation of the grievance to the Grade Grievance Committee consisting of the Chair of the Course/Clerkship Committee, or designee if it involves his/her course/clerkship, and three faculty familiar with the medical education program who are not involved in the same course/clerkship as the grievance or are members of the ASC. A 4th year medical student from the ASC will serve as a non-voting member on the Grade Grievance Committee. The faculty members of the Grade Grievance Committee are appointed by the Associate Dean of Medical Education.
3. After review, the Grade Grievance Committee will submit a recommendation to the Associate Dean for Medical Education and the Chair of the Academic Status Committee who will review the report and provide the response to the student.
4. The decision of the Associate Dean for Medical Education and the Chair of the Academic Status Committee is final.

The UF Office of the Ombudsman is another resource for students with a university related problem and/or concern. For additional information about the Office, see http://www.ombuds.ufl.edu/.

Required clinical presentations, skills, and procedures

The clerkship is designed to expose you to the following core presentations, skills, and/or procedures, which are graduation requirements. If you have difficulty meeting any of these, an alternate method is listed in the table below.

Graduation requirements:

Patient Logs
The patient logs are a College of Medicine graduation requirement. To help you stay on track with this requirement, we identified 12 core clinical experiences that you should be able to see during this rotation. You are required to log these 12 presentations and if you do not have a patient with the presentation, you may use the AQUIFER INTERNAL MEDICINE cases you completed as a substitute. Failure to log may result in a reduction in your grade or an incomplete for the clerkship. If a patient you already logged develops a new problem, you may log that in as a separate entry.

• Anemia
• Arrhythmia
• Cancer
• Chest Pain
• Chronic Kidney Disease
• Congestive Heart Failure
• Electrolyte Disorders
• Liver Failure
• Lymphadenopathy
• Sepsis
• Shortness of Breath
• Pre-Syncope or Syncope

Abnormal Data (pocket card provided for tracking)

• CBC
• MP
• LFT
• INR
• BNP
• Ferritin
• Blood culture
• CT chest
• CT head
• ECG – basic arrhythmias
• ECG – ST elevation
• ECG – ST depression

Abnormal Physical Exam Findings (pocket card provided for tracking)

• Orthostatic Vital Signs
• Petechiae
• Jaundice
• Ascites
• Edema
• S3
• Elevated JVP
• Heart murmur
• Irregularly irregular pulse
• Goiter/abnormal thyroid exam
• Crackles
• Dullness to percussion

In addition to the graduation requirements, the Medicine Clerkship also requires the following:

Clerkship Requirements:

• SMART Goals (To be reviewed during mid-clerkship feedback session)
• Reflective Writing Session
• Formative Feedback Reflections 4.Mini-CEX History and Mini CEX Physical Exam (two of each)
• Aquifer High Value Care Modules 1 and 5
• Patient Log (12 core presentations required)
• **Physical Exam Checklist
• 4 Write-Ups: Submitted Friday of Weeks 2,4,6, and Sunday of Week 8. Including real time EBM.
• PMEX (2 faculty/housestaff, 1 peer, up to 1 clerkship coordinator)

** Items are University of Florida College of Medicine Requirement

Clerkship requirements should be submitted on Canvas by 11:59pm the Sunday after the last day of the clerkship, unless earlier due dates are noted.

Video instructions on how to complete case logs in New Innovation are on the Phase 2 Canvas Page.

Policy on student evaluations

• Each student must complete at least 75% of all assigned faculty, resident, and small group leader evaluation forms associated with a course/clerkship in each year of enrollment. There is an expectation of 100% completion on overall course and clerkship evaluations.
• Every student is expected to respond in a professional manner to each item which she/he feels qualified to answer.
• Strict confidentiality of responses is assured. Evaluation data (numerical ratings and student comments) is de-identified. However, the completion of evaluations will be tracked.

COLLEGE OF MEDICINE POLICIES AND PROCEDURES HANDBOOK

The following topics are covered in the College of Medicine Policies and Procedures Handbook