Combined Inpatient & Outpatient US Clinical Experience in Internal Medicine in San Francisco

Information about this clinical experience:

This is a combined inpatient and outpatient experience during which you will be under the supervision of a board-certified internal medicine physician with an extensive background in teaching, having served in the past as chief resident and residency program director. The physician is a member of the American College of Physicians and has been awarded the status Fellow of the American College of Physicians (FACP), a distinction awarded to a small percentage of members for excellence in medical practice, teaching, or research.

The physician is actively involved in the education of future doctors and currently serves as faculty of a family medicine residency training program. Every week, residents from the program spend a ½ day with this attending. During this time, a 1.5 hour Zoom lecture/didactic is delivered to the trainees. Rotators may also attend this Zoom session.

The outpatient component of this clinical experience will take place at assisted living facilities. These facilities provide support and care to elderly patients who need assistance with their activities of daily living. In addition to helping with daily tasks, personnel may aid with medications and personal care. You will accompany your preceptor on visits to these facilities to assess the health of residents, provide medical care, and address any concerns.

The inpatient component of this clinical experience will take place at nursing homes. Residents reside in nursing homes when they have severe illness, disability, or cognitive impairment. As patients in nursing homes tend to be older and have multiple comorbidities, the care of these patients can be medically and socially complex. Research shows that, among graduating residents, over 20% feel unprepared to care for nursing home patients. As a result, the Institute of Medicine has urged residency programs to adopt nursing homes as sites for medical training. Despite this recommendation, only a small percentage of residency programs offer trainees the opportunity to engage in nursing home care. Therefore, your visits to the nursing home with the preceptor will be a chance for you to build the skills and knowledge needed to care for this patient population. The following articles, although a bit older, provide a great overview of important concepts in nursing home care:

Nursing Home Care: Part I: Principles and Pitfalls of Practice

Nursing Home Care: Part II. Clinical Aspects

Goals of this clinical experience include:

• Gaining experiencing in assessing and managing common acute and chronic medical problems in nursing home residents, such as heart failure, diabetes, dementia, wounds, falls, pneumonia, osteoarthritis, and urinary incontinence.

• Learning how to evaluate and manage behavioral symptoms of dementia with non-pharmacologic and pharmacologic approaches.

• Reviewing medication list to weight benefits and risks of each medication, taking into account the evidence in the field, the patient’s goals, and life expectancy.

• Developing rapport and trust with patients and families.

• Conveying information and providing explanations to patients and families in understandable ways.

• Assessing capacity of patient to make treatment decisions.

• Recognizing ethical issues encountered in long-term care.

During your experience, you will learn the following U.S. medical practices under the preceptor’s supervision (please note that this experience remains within the regulations of California pertaining to the unlicensed practice of medicine):

• Taking patient histories under supervision.

• Performing physical exams under the physician's supervision.

• Presenting patients.

• Writing or entering notes in the EMR (Point Click Care and Ethizo EMR)

• Have opportunities to research the literature to answer clinical questions at the point of care.

• Being involved in patient education.

• Spending time with other healthcare professionals to understand their roles and responsibilities.

Please note that you will also spend time with the preceptor’s nurse practitioner. As nurse practitioners will be members of your team during residency, this will be an excellent opportunity to understand their roles and responsibilities so that you can effectively collaborate with them.