Foundations of Doctoring Curriculum

The FDC in Phase I is composed of:

• Physical examination sessions
• Communication coaching sessions
• Continuity clinic with a physician preceptor (preceptorship)
• Professional development sessions and activities
• Assessment of your clinical skills  

FDC Phase I Goals (PDF with objectives)

• Know and use the language of physical examination structures, techniques and findings.
• Relate the physical examination to normal anatomy and physiology.
• Relate the physical examination to abnormal anatomy and pathophysiology.
• Perform basic physical examination techniques on adults and children in the following areas:
  • General Assessment (Vital Signs)
  • Extremities and Back
  • Cardiovascular
  • Chest and Lungs
  • Abdomen
  • Head and Neck
  • Skin, Hair and Nails
• Know and use the language of relationship centered clinical encounters and communication techniques specific to introductions and agenda settings, information gathering, sustaining structure and relationships and closing and forward planning.
• Identify the key subjective and objective components of the patient data base gathered in the encounter: patient identification, chief complaint, history of present illness, active medical problems, past medical history, medications, allergies, social history, family history, and physical exam findings.
• Identify the key components of the SOAP note.
• Practice writing SOAP notes and avoiding common pitfalls in SOAP note writing.
• Know and use the language of fundamental clinical reasoning concepts, including problem representations, semantic transformation, and key features.
• Practice clinical reasoning skill through creation of accurate problem representations, identification of key features of the patient's subjective and objective presentation, and creation of a summary statement using semantic qualifiers.
• Practice a hypothesis-driven approach to history taking and physical examination based on the patients presenting complaints.
• Practice compassionate treatment of patients, and respect for their privacy and dignity.
• Uphold and promote the ideals of medical professionalism in all interactions with patients, colleagues, staff and faculty.
• Recognize and accept limitations in one’s knowledge and clinical skills, and a commitment to continuously improve one’s knowledge and ability.
• Recognize the importance of cultural, ethnic, racial and religious diversity and its impact on society, health care delivery, and the workplace.
• Recognize the impact of economics on healthcare delivery
  Identify the basic legal obligations of clinical practice.
• Understand and respect the roles of other health care professionals and the need to collaborate with others in caring for individual patients.
• Identify characteristics of effective teamwork.
• Begin career exploration.​​​

As you enter the second phase of the Foundations of Doctoring Curriculum, you will be building on many of the skills you learned in Phase I.

• Continuity clinic with a physician preceptor (preceptorship)
• Advanced physical examination sessions
• Advanced communication sessions
• Complete History and Physical (H&P) write-up
• Oral presentation skill session
• Professional development sessions and activities
• Assessment of your clinical skills

FDC Phase II Goals (PDF with objectives)

• Relate the physical examination to normal anatomy and physiology.
• Relate the physical examination to abnormal anatomy and pathophysiology.
• Know variations in physical exam techniques for use with children and the elderly.
• Perform basic physical examination techniques on adults and children in the following areas: General Assessment (vital signs); extremities and back; cardiovascular; chest and lungs; abdomen; head and neck; hair and nails, neurologic, eyes, and uro/gyn.
• Perform a head-to-toe core physical exam based on a provided checklist of items that would be appropriate for the performance of a complete history and physical.
• Know and use the language of relationship centered clinical encounters and communication techniques specific to introductions and agenda settings, information gathering, sustaining structure and relationships, closing and forward planning, sharing information, and negotiating a treatment plan.
• Begin to use appropriate relationship centered communication techniques in difficult clinical encounters.
• Know the content of and practice taking a sexual history.
• Identify the key subjective and objective components of the patient data base gathered in the encounter to perform a complete history and physical: patient identification, chief complaint, history of present illness, active medical problems, past medical history, medications, allergies, social history, family history, review of systems, and physical exam findings.
• Identify the key components of the history and physical write-up, SOAP note and oral presentation.
• Understand the fundamental clinical reasoning concepts, including problem representation, semantic transformation, key features, illness scripts, and differential diagnosis.
• Obtain an accurate medical history that covers all essential aspects of the patient data base, including issues related to age, gender, and socioeconomic status.
• Practice writing a full history and physical, SOAP notes and performing oral presentations.
• Know clinical reasoning concepts including analytical and intuitive reasoning techniques to solve clinical problems and develop assessment and plans for patients.
• Use comparison and contrast routinely in analyzing differential diagnoses.
  Demonstrate the use of a hypothesis-driven approach to history taking, physical examination, and data collection.
• Understand analytical methods for patient differential diagnosis such as prioritized, system based, and pathophysiologic techniques.
  Practice compassionate treatment of patients, and respect for their privacy and dignity.
• Uphold and promote the ideals of medical professionalism in all interactions with patients, colleagues, staff and faculty.
• Recognize and accept limitations in one’s knowledge and clinical skills, and a commitment to continuously improve one’s knowledge and ability.
  Recognize the importance of cultural, ethnic, racial and religious diversity and its impact on society, health care delivery, and the workplace.
• Know basic concepts of quality improvement, patient safety, and leadership through completion of the IHI Open School Basic Certification.​​​

How we communicate dramatically impacts the kinds of relationships we can build with patients and their families. These relationships in turn, influence information-sharing, diagnostic accuracy, compliance with plans of care and care coordination. As a result, communication is our most powerful therapeutic tool and the one we will use most frequently in our professional lives.

The model of communication used in our workshops is based on the Calgary-Cambridge Guide. We chose this model because it provides diverse and specific communication skills aimed to structure clinical encounters effectively and efficiently while facilitating relationship centered care. The Calgary Cambridge skill base is also useful outside the interpersonal clinical encounter and is easily transferable to peer and collegial relationships, as well as interprofessional clinical teams. It is also highly adaptable to difficult encounters featuring emotions, multiple parties, and complex conditions while allowing the healthcare professional to adopt role flexibility as the clinical situation evolves. Our goal in using this model is to guide students in their own customized, relationship centered communication and care style.

In the first year of the FDC, we lay the foundation for communicating with patients in an interactive curriculum that includes two exercises in information gathering and relationship building skills using small group coaching sessions and a digital recording review session of standardized patient encounters. In Phase 2 of the communication curriculum, we focus on communication skills related to explaining and planning care for patients, including how to collaborate with patients in modifying behaviors, manage difficult encounters, write up a formal H & P and perform oral presentations. Students are encouraged to construct skill based learning objectives for their communication sessions and to practice these skills in their preceptor experiences. We also work closely with the Center for Advancing Professional Excellence (CAPE) and develop specific standardized patient (simulated patient) cases to address different clinical encounters and the requisite combination of communication skills.

The physical exam curriculum teaches students the fundamental skills needed to perform a complete physical exam on patients of all ages. This portion of the curriculum was designed to compliment the other skills taught in the Foundations of Doctoring Curriculum. As students learn to do focused physicals, they learn to incorporate their history taking skills, preceptor experiences and clinical reasoning skills to choose and perform relevant physical exam maneuvers.

Goals

• Learn how to perform a complete physical exam on children and adults.
• Identify and perform the physical exam elements as it relates to a specific chief complaint.
• Ascertain the correct information from each physical exam test.
• Learn how to incorporate the physical exam into your understanding, diagnosis and treatment of patients
• Pass the USMLE Step 2 Clinical Skills Exam.

Gr​ading

• The course assesses the following competencies: patient care including clinical skills and clinical reasoning, professionalism, practice based learning and improvement.
• For the small groups session, attendance is required to pass the course.
• Students must also pass an annual Observed Structured Clinical Examination (OSCE).

Physical Exam - Phase I

‪The first year (Phase I) curriculum involves learning how to perform a physical exam on a healthy adult. The sessions are held at the state of the art simulation center (CAPE), where the class is divided into small groups to work with standardized physical exam teaching assistants (SPETAs), under the supervision of the simulation center professionals and course directors. 

‬Normal Physical Exam​

The physical exam sessions are divided by organ systems and are taught in conjunction with the musculoskeletal block. Students correlate the physical exam maneuvers with the anatomy learned during dissection laboratories. Students are provided checklists, study guides, learning objectives and a reading assignment from Bates’ Guide to Physical Exam and History Taking for each session.

​Normal Exam:

• Vital Sign
• Lower Extremity Musculoskeletal Exam
• Upper Extremity Musculoskeletal Exam
• Cardiac
• Pulmonary
• Abdomen
• Head and Neck
• ​Abnormal Physical Exam

Once the physical exam is mastered on the healthy adult, first year student begin learning how to identify and describe abnormal findings. The abnormal physical exam sessions are designed to demonstrate the abnormal physical exam findings associated with the disease and pathophysiology that the students are learning about in their didactic and small group sessions. Most of the sessions are taught is small groups, facilitated by attending faculty and residents. Most of these sessions are performed on real patients, and students are encouraged to use their clinical reasoning skills to perform an appropriate and focused exam.

Abnormal Exam:

• Cardiac
• Pulmonary
• Skin, Hair and Nails

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Physical Exam - Phase II

The second year (Phase II) medical students begin the year learning how to perform more complex and advanced physical exam skills. 

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Ophthalmologic & Neurological Physical Exams​​​

In small groups, ophthalmology faculty and residents teach students to perform the ophthalmologic exam with the indirect, coaxial and panoptic ophthalmoscopes, as well as the slit lamp. Likewise, in small groups, neurology faculty teach the students how to use a bag full of diagnostic equipment to elicit all components of the neurological exam.

Students are provided checklists, study guides, learning objectives and a reading assignment from Bates’ Guide to Physical Exam and History Taking for each session.

Normal Exam:

• Ophthalmologic Exam
• Neurological Exam

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Abnorm​al Physical E​​xam​

The students also complete the abnormal physical exam sessions. This is a continuation from the first year. The abnormal physical exam sessions are designed to demonstrate the abnormal physical exam findings associated with the disease and pathophysiology that the students are learning about in their didactic and small group sessions. Most of the sessions are taught is small groups, facilitated by attending faculty and residents. Most of these sessions are performed on real patients, and students are encouraged to use their clinical reasoning skills to perform an appropriate and focused exam.

Abnormal Exam:

• Abdomen (Digestive and Endocrine)

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​Breast and Pelvic Exams​​

​In preparation for the preceptor experience and clinical clerkships, students learn how to perform breast and pelvic exams, including PAP smears on standardized physical exam teaching assistants (SPETAs). They also learn the urologic and prostate exams on SPETAs. Students are provided checklists, learning objectives and a reading assignment from Bates’ Guide to Physical Exam and History Taking for each session.

Normal Exam:

• Breast and Pelvic Exam
• Male Genital and Rectal Exam

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Pediatric and Geriatric Physical Exams​​

After learning all aspects of the adult exam, students then translate and adapt their skills to patients at both ends of the age spectrum. In small groups, students learn the toddler and child exams on real patient under the supervision of pediatric and family medicine faculty and residents. Geriatrician faculty demonstrate the unique components involved in the assessment of an elderly patient and students get the opportunity to practice these skills on real patients. Students are provided learning objectives and a reading assignment from Bates’ Guide to Physical Exam and History Taking for each session.

Normal and Abnormal Exams:

• Pediatric Exam
• Geriatric Adult Exam

Several other curricular topics are integrated within the Foundations of Doctoring Curriculum, including Clinical Reasoning, Threads, IHI Open School Modules and the Clinical Interlude. 

Clinical reasoning curriculum

Clinical reasoning or “how to think like a physician” is a complex skill that is learned and developed throughout a physician’s medical career.  Although medical students have historically learned clinical reasoning through the process of going through medical school and refined these skills once in residency and out into practice, there is a push in undergraduate medical education to teach clinical reasoning more explicitly.  Within FDC communication, physical examination, preceptor, and didactic sessions, fundamental concepts of clinical reasoning will be introduced and reinforced through opportunities to practice clinical reasoning skills using both application and reflective exercises.  Sessions focusing on the creation of written notes and oral presentations will highlight the importance of using clinical reasoning skills to create hypothesis-driven histories and physicals that support prioritized assessments and diagnostic and therapeutic plans for patients. Supplemen​tal readings for these educational sessions will be used to help reinforce clinical reasoning concepts and skills.  Clinical reasoning knowledge, behaviors, and techniques can and should be used and applied in problem based learning sessions, preceptor sessions, and other clinical experiences to develop one’s abilities to “think like a doctor.”

Threads

As in the Essentials Core Blocks, Threads content is integrated into FDC curricular time.  In Phase I, there are sessions in the Humanities, Ethics and Professionalism (HEP), Medicine and Society (M&S), and Culturally Effective Medicine (CEM) threads.   

Assessment of your progress is accomplished in a manner that is congruent with the goals of the curriculum. The FDC uses a broad array of methods appropriate to assess all competencies fairly. Your preceptor will evaluate you at the end of each semester.  Attendance and active participation is required for all sessions and all assignments must be completed. 

Physical exam and communication skills assessment will take place during phases I and II at the Center for Advancing professional Excellence (CAPE). This type of evaluation has taken on more importance in medical education as you will be required to take a similar style exam during part II of the National Boards. In addition, Blocks will integrate Foundations content into their exams (e.g. physical exam knowledge in the Human Body Block). As in other courses, FDC assessment material (including case content) is confidential and revealing this information to peers will be considered an honor code violation. FDC is a Pass/Fail course.​