Met 3B Community Clerkship:
Long Term Condition Management
Introduction
The following document outlines the content and delivery plan for an innovative module of teaching in primary care. General practitioners and their community team colleagues are well placed to deliver continuity of care to those patients suffering from long term conditions, often multiple in nature, which are increasingly managed in the community. We wish our students to experience this community-based healthcare, explore the challenges involved, and develop a better understanding of the current management of these conditions. We believe this will increase their understanding of the conditions themselves and their impact for the patient, the health economy and local communities, including better communication between hospital and primary care.
Met 3B currently is a 10 week attachment – with one week of introductory lectures followed by nine weeks on hospital attachment, during which there are four days in general practice. This pilot changes this balance to three days a week in hospital and two days a week for the 9 clinical weeks in general practice reflecting the changing face of clinical medicine and provide a more diverse learning experience for junior clinical students.
The key learning objectives for Year 3 can be summarised as:
- learning to take a comprehensive medical history
- perform a full examination
- make sense of clinical findings (clinical reasoning).
All of these key learning objectives can be achieved within the model of general practice where both a holistic and student-centred approach is adopted. Students are encouraged to apply clinical reasoning to a fuller history and examination that can be closely supervised and taught in a safe learning environment. General practitioners and the breadth of healthcare professionals will be able to identify suitable patients from whom students can learn. This learning will be supported by witnessing role models of good community-based care and discussing the practicalities of management in context. This document serves as an accompaniment to the year 3 Met 3B log book issued to the students and available at http://qmplus.qmul.ac.uk/pluginfile.php/246866/course/section/123225/MET3B%20Student%20Logbook%202014-15.pdf .
As a general overview, students are required to complete the following activities during their time on their whole attachment in the nine clinical weeks of Met 3B:
· Short history taking – 6 in hospital, 4 in this clerkship
· Full history taking – 6 in total, (3 to be completed in this clerkship)
· Case Presentation – 6 in total, (3 to be completed in this clerkship)
· PBL attendance and reflection
· Practical skills – as outlined in the Met3B logbook
· Common and Important conditions – observe and read up
· Observed procedures – observe and read up
· Shadowing experience in hospital
· Selected Study Component (SSC) – can be completed in General Practice
Many of these activities can be completed in general practice but we ask you to concentrate in particular on the highlighted learning objectives that follow. Students often view their key objective to be to get their log book sign ups completed and, whilst tutors should be mindful of addressing this natural anxiety, the need to see and work with a wide variety of patients with long term conditions is essential. It would be worthwhile in the first session of the attachment to have an introductory meeting including planning a timetable and going through the student logbook.
The specific learning objectives for Met3B are listed in more detail on the Barts and the London Medical School COMPAS site (curriculum map) available at http://compas.smd.qmul.ac.uk . It is, however, worth noting that much of the theory will have been addressed in lectures/previously taught sessions in earlier years and year 3 is aiming to consolidate their clinical knowledge with patient contact.
Core topics
The common and important conditions that Met 3B covers are listed below and primary care will be able to identify patients that will offer opportunities for students to cover these topics. All are those seen in patients as long term conditions:
Renal conditions - Acute renal failure
- Chronic renal failure
- Diabetic nephropathy
- Obstructive uropathy
- Renal/bladder/prostate cancer
Diabetic conditions - Type 1 diabetes
- Type 2 diabetes
- Complications of diabetes
Endocrine conditions - Thyroid disease
- Pituitary disease
- Adrenal disease
- Disorders of calcium metabolism
- Breast Cancer
Learning outcomes
It is important to remember that the aim of this pilot is to expose students to the primary care presentation, management of the relevant long term clinical conditions, and the relationships between primary and secondary care. Whilst some of the learning objectives are not suitable for delivery in primary care – such as the surgical approach to renal tumours and transplantation – below is a summary of the learning outcomes that can be addressed in primary care. The highlighted learning outcomes should all be achievable from an experience in primary care.
Please do also bear in mind that the students will be spending 5 weeks of their attachment in the hospital setting and there is not an expectation that tutors will need to teach all of the below theory. Students are expected to be able to engage in self directed learning and GP tutors able to facilitate learning on the topic by providing appropriate primary care clinical illustrations of these.
Chronic Kidney Disease
1. Be able to identify and differentiate between acute (ARF) and chronic renal failure (CRF) and their presentation in primary care
2. Be able to describe the CKD classification of CRF and its progression including the monitoring of proteinuria
3. Understand the importance of blood pressure control in attenuating the progression of CRF including the use of drugs that block the renal angiotensin system
4. Understand the effects and management of the complications of CRF such as anaemia, secondary hyperparathyroidism, bone disease and impaired immunity.
5. Appreciate the importance of the integration between primary and secondary care in the long term management of CKD
Obstructive uropathy
1. Be able to describe common Lower Urinary Tract Symptoms (LUTS)
2. Understand the assessment of patients with LUTS and the role of benign prostatic hypertrophy
3. Know the medical and surgical treatment options of patients with LUTS
4. Discuss the aetiology and pathological consequences of calculi in the kidney and ureter
5. Understand the investigations required to diagnose renal calculi
6. Understand the role of diet in treating patients with renal calculi
Renal/bladder/prostate cancer
1. Understand the significance of microscopic and macroscopic haematuria
2. Describe the clinical features and red flag symptoms of patients with renal tract tumours
3. Be able to describe the investigations available to establish a diagnosis of renal tract malignancy including urine cytology, endoscopy and imaging
4. Understand the use and limitations of prostate specific antigen (PSA) in the diagnosis and monitoring of prostate cancer
Diabetes Mellitus (please remember that students will receive most of their theory teaching from hospital and the aim is to provide opportunities for learning via patient contact)
1. Be able to differentiate between Type 1 and Type 2 diabetes
2. Recognise the contribution of genetic and environmental factors in the aetiology of Type 1 and Type 2 Diabetes Mellitus
3. Know the diagnostic criteria for (DM), impaired fasting glycaemia (IFG), and impaired glucose tolerance (IGT) and pre-diabetes
4. Know the presentation and initial management of diabetes
5. Understand why good glycaemic control is important, and be aware that targets for glucose control may vary between individuals
6. Understand the indications and side effects of the various classes of oral hypoglycaemic agents / newer injectable agents
7. To be able to describe common insulin regimes and prescribe insulin safely
8. Describe the long term complications of diabetes – microvascular, macrovasular, other
9. Be aware of the importance of education, preventative medicine, early recognition of complications
10. Know the importance of regular screening for complications of diabetes
11. Know the goals for treatment of hypertension, lipids and glycaemia to prevent vascular complications
12. Recognise an acutely unwell diabetic patient – hypo/hyperglycaemia and their management
13. Be aware of the psycho-social impact of diabetes complications on the individual with diabetes and society in general
Thyroid Dysfunction
1. Define goitre, list the causes and briefly describe the pathology
2. Define the role of isotope scanning, ultrasound and fine needle cytology in the investigation of thyroid lesions
3. Distinguish thyroid enlargement from other lesions in the neck by examination
4. Be able to define the various benign and malignant tumours of the thyroid
5. Know the clinical features, investigations and management of patients with hypo- and hyperthyroidism
Diabetes Insipidus and Hyponatraemia (possible tutorial or can be hospital led)
1. Understand the causes of hypernatraemia and hyponatraemia
2. List the causes of thirst and polyuria
3. Describe the initial investigations which help to distinguish cranial and nephrogenic diabetes insipidus and psychogenic polydipsia
Pituitary Hypothalmic Axis (possible tutorial or can be hospital led)
1. Be able to list the hormones secreted by both the anterior and posterior pituitary and their actions
2. Describe the clinical features, investigations and management of syndromes of pituitary hormone excess (acromegaly, Cushings, hyperprolactinaemia) and insufficiency- if you have suitable patients
Endocrine Hypertension (possible tutorial or can be hospital led)
1. Describe the presenting clinical features of Conn's Syndrome and phaeochromocytoma
2. Know the strategy for investigation of endocrine hypertension including suspected Conn's syndrome and phaeochromocytoma
Breast disease
1. Take a history of breast symptoms and assess the risk factors for breast disease
2. Be able to carry out an examination of the breasts including examination of the axillary lymph nodes and lymph node drainage sites
3. Recognise the role of ultrasound, mammography and cytology and the 2 week wait referral
4. Evaluate the role of breast screening programmes
5. Recognise the features of benign breast disease eg fibroadenoma, multi-duct nipple discharge, breast cysts, cyclical mastalgia
6. Know the risk factors, incidence, mortality, and prevention of common breast cancers
7. Understand the treatment of early breast cancer to maximise cure
8. Understand the treatment of metastatic breast cancer to optimise palliation
9. Be aware of the role of rehabilitation and supportive care, and appreciate the role of a multi-disciplinary team approach to breast cancer
Delivery
The module has been set up to be delivered over the course of 2 days a week over 9 weeks in primary care. During the 9 weeks they will have 2 or 3 weeks off for in course assessments and to attend their breast surgery and urology weeks. There is not an expectation to cover all of the subject material outlined above but to provide a diverse learning experience to the students and realistic exposure to how chronic disease is managed in primary care.
The students will attend 2 days a week – Thursdays and Fridays in General Practice. During the 2 days there is payment provision for:
Two 100% contact sessions – e.g. tutorial, directly observed consultations/clinical skills
One 50% contact sessions – e.g. participation in/running chronic disease clinics, attend GpwSI clinics/community MDT clinics
One 25% contact sessions – e.g. accompanying a patient to an outpatient clinic/dialysis and interviewing them pre and post appointment, accompanying the district nurse on home visits, both of which requires tutor time in organising and briefing and debriefing the students.
The students are required to conduct a Selected Study Component during the course of the term which involves interviewing a patient whilst being observed by a peer, and writing up a self appraisal of the interview taking into account the peer feedback received. Along with this they are also required to write an essay on a topic the subject of which is triggered by their discussion with the patient. The SSC can be delivered either in the hospital or in GP and please discuss with the student where they would prefer to do this.
Model timetable
Thecontent of the teaching sessionswill vary from practice to practice, and with the availability of different types of patients. However we recommend you include a balance of the activities listed below.
Day 1 / Day 2 / Day 3 / Day 4 / Day 5AM / Visit a housebound pt , e.g. home dialysis and report back to GP after to discuss the pre-arranged learning objectives / Nurse/student led clinic – e.g. diabetes clinic looking at specific objectives, i.e. common presentations or complications, medication, etc. with suitable supervision/discussion opportunities / Accompany patient to outpatient appt/A+E and explore their thoughts before, during and after the consultation / Reflect on week’s activities/prepare topic for tutorial
Surgery participation / District nurse home visits
PM / SSC / Directly observed consultations/clinical skills / Students off / Tutorial with GP and case presentations and/or history taking / Nurse/student led clinic – e.g. CKD clinic,
Audit, patient case studies
Medical interviews and explanations to patients
Taking histories from patients either individually or in pairs; preferably observed by tutor or other students so the student gains feedback. Practising communication skills with patients by giving explanations concerning their condition or its management. E.g. a student has looked up the drug treatment of asthma and then explains the way inhalers work to a patient.
Examining patients and visiting patients at home
Either focusing on a particular system or a complete examination. Feedback from tutors and other students is important. Initial sessions may require some tutor demonstrations and assisted student examinations. Also, use visits to patients’ homes to explore coping mechanisms and difficulties in activities of daily living when long-term conditions exist.
Practical skills
Such as urinalysis, checking BM, blood pressure measurement and spirometry
Presentation skills
Listening to students presenting histories or examination findings.
Doctor as model and role playing
Observation of the doctor modelling history taking or examining a patient. (However GPs should not always combine teaching with a consultation workload). Role playing is a good way for students to gain confidence and the role-player may also benefit from empathising with the patient’s perspective.
Student led and tutor directed learning
Students will need to cover a large proportion of the curriculum through private study. While they are with you there will be many triggers for their learning. Tutors can encourage and direct this learning, by asking students to look up something specific for the next week, or recommending reading. Some useful references are given in the tutor handbook for each system –based day.