What to Expect at Your Outpatient Site

Your internal medicine outpatient site is where you will have your principle clinical experience. In general, here is what you can expect at your site:

  1. An orientation session
    1. Early on during your first day in the clinic you should have an orientation session with your preceptor. This discussion is critical to getting you off to the right start. Topics that should be covered are listed in the section on "Suggestions for Success in the Ambulatory Setting" in the CDIM Primer to the Internal Medicine Clerkship, including:
      1. General information about how the clinic is set up.
      2. What time clinic starts and when you should arrive?
      3. Will you be shadowing the preceptor initially? If so, does the preceptor want you to ask any questions or just observe? When will you start seeing patients independently (see #2 below)?
      4. Will the preceptor pick specific patients for you?
      5. Will the preceptor provide you with information on the patient prior to your seeing the patient?
      6. How do you know when a patient is ready for you to see?
      7. Will you be seeing and examining the patient entirely on your own and then presenting to the preceptor or will you collect just the history and then conduct the examination together?
      8. How detailed should the physical examination be?
      9. How much time is allotted for you to take the history, conduct the exam, and present the case?
      10. Where should you document your note? How detailed should it be?
      11. How should you follow-up on test results?
      12. How are test results communicated to the patient?
      13. How and when will you receive feedback on your performance (see #6 below)?
  2. Active participation by you in patient care
    1. Your preceptors understand that, at this phase in your education, you need to participate actively in patient care. They also know that you are not ready to practice on your own and that lots of coaching and supervision is warranted. You will not be left on your own.
    2. After an initial brief period of passively observing your preceptor, you should expect to see at least four patients per day (two per 1/2 day session) on your own. Your preceptor will usually brief you about the patient beforehand and set goals for your interaction with the patient. Always, your preceptor will see the patient with you at the conclusion of your independent evaluation.
    3. For an additional number of patients, your preceptor may ask you to see them on your own, but not to assume responsibility for total care. For example, you may be asked to see a patient briefly to obtain a focused history, review medications, or make a preliminary diagnosis.
    4. It can not be stressed enough that the most important feature of your clinical experience is the opportunity to evaluate patients on your own and to solve problems related to patient interviewing, physical examination, differential diagnosis, and treatment. While passive observation of your preceptor will be an important adjunct to your clinical instruction, it should not constitute the majority of your time with patients. If you find that you are observing your preceptor for a majority of your patient encounters, please contact Carol Carden and/or Dr. Shaheen. We will do our best to ensure that you have an appropriate clinical experience.
    5. When working independently let the following steps serve as a guide:
      1. introduce yourself (if preceptor has not already done so), informing the patient that you are a medical student working with the patient's physician
      2. determine if the visit is for an acute complaint, for management of chronic issues, or both
      3. perform an appropriately focused interview and physical examination
      4. formulate a differential diagnosis and consider appropriate diagnostic and therapeutic strategies
      5. tell the patient that the preceptor will return with you to review the situation
      6. present the patient's history and physical examination, your differential diagnosis (if indicated), and your proposed diagnostic and therapeutic strategies
      7. ideally, have a “teaching moment” with your preceptor
      8. reevaluate the patient with the preceptor
      9. discuss the assessment of the problem and the recommendations with the patient
      10. order appropriate tests and write prescriptions (with the preceptor's approval)
      11. perhaps write or dictate a progress note and have the preceptor review it
      12. follow-up on test results
      13. see the patient in follow-up, if indicated
      14. pay attention to your schedule and the patient's - try not to keep patients and your preceptor waiting
  3. Integration into the practice
    1. You are encouraged to participate in all activities of the practice. Assume an active, interested role as you contribute to the office evaluation of patients. Although not required, you may also arrange with your preceptor to take part in administrative planning, hospital rounds, emergency room visits, night call, or home visits.
  4. Opportunity To Write Notes
    1. By the end of this outpatient clerkship, you should be able to write a concise, well-organized visit note. Your preceptor might ask you to write a note on some, if not all, of the patients you see. At some clinical sites, your note will be included in the patient's official record, countersigned by your preceptor. At sites where the preceptor dictates a note or where an electronic medical record is used, students may not be encouraged to write any formal note (other than the informal notes taken during the interview). You are encouraged to write a formal, complete note (including assessment and plans) on at least one patient you see each day. This note can be written after the clinic session has ended. You should give the note to your preceptor and ask for feedback. Please see the section on Notes for some suggestions for writing an outpatient note and to see some sample notes.
  5. An expectation of self-directed learning
    1. You may happily note one major distinction between hospital-based practice and office-based practice: offices generally close in the evening. For you, the uncluttered evenings will be a time to read about your patients, to research questions that arose during the day and to complete the required readings and the computer problems. Preceptors have been specifically asked to look for evidence that you have read articles and books between clinic sessions. You are encouraged to use the evenings and other free time to expand your knowledge of internal medicine and to learn from your patients.
  6. Feedback
    1. There will be many opportunities during your outpatient clerkship for feedback on your performance. Informal feedback will often come serendipitously during regular clinical work from your own observations, comments from your patients, and remarks by your preceptor. In addition, however, you are required to have a mid-clerkship feedback session with your preceptor. Please discuss the timing of this feedback session early in the rotation.
    2. The Medicine Clerkship Log allows you to document that you had a formal feedback session with your preceptor during which you received an interim assessment of your progress. This assessment should formative feedback, meaning that you should receive explicit recommendations for improvement.
    3. Please review the RIME framework, the clerkship Learning Objectives, and information on the Grading page to help guide your mid-clerkship feedback session.