Integrating the Curriculum Integrating the Curriculum with Clinical Medicine with Clinical Medicine

Richard Usatine, MDRichard Usatine, MD

Early introduction of Clinical Early introduction of Clinical MedicineMedicine

• Teaching basic clinical skills – in Teaching basic clinical skills – in physical exam coursesphysical exam courses

• Preceptorships - early clinical Preceptorships - early clinical experiences in the communityexperiences in the community

Early introduction of Clinical Early introduction of Clinical MedicineMedicine

• PBL or clinical case-based teaching in PBL or clinical case-based teaching in small groupssmall groups

• Clinical correlations in “Basic Clinical correlations in “Basic Science” CoursedScience” Coursed

Doctoring at FSU Doctoring at FSU

• Clinical case-based teaching in small Clinical case-based teaching in small groupsgroups

• Teaching basic clinical skills – in our Teaching basic clinical skills – in our Clinical Learning CenterClinical Learning Center

• PreceptorshipPreceptorship

• Medical InformaticsMedical Informatics

Doctoring GoalsDoctoring Goals

• Communication SkillsCommunication Skills

• Physical Exam SkillsPhysical Exam Skills

• Clinical decision-makingClinical decision-making

• EBMEBM

• EthicsEthics

• HumanismHumanism

• Clinical application of sciencesClinical application of sciences

Horizontal IntegrationHorizontal Integration

• Coordinated with Coordinated with – PathologyPathology– MicrobiologyMicrobiology– PharmacologyPharmacology– Health issues in medicineHealth issues in medicine– Psychosocial aspects of medicinePsychosocial aspects of medicine

Vertical IntegrationVertical Integration

• Doctoring 1 – Focus on basic Doctoring 1 – Focus on basic interviewing, developmental interviewing, developmental psychologypsychology

• Doctoring 2 – Cases based on common Doctoring 2 – Cases based on common diseasesdiseases

• Doctoring 3 – Cases based on the 20 Doctoring 3 – Cases based on the 20 health priority areas of the IOMhealth priority areas of the IOM

• Each year builds directly on the Each year builds directly on the preceding yearpreceding year

DoctoringDoctoring

• Simulate a clinical practiceSimulate a clinical practice

• Every student sees the same basic Every student sees the same basic core casescore cases

• Patients return over time to simulate Patients return over time to simulate continuity and to see time course of continuity and to see time course of various conditions – breast cancer, various conditions – breast cancer, prostate disease, asthma, depressionprostate disease, asthma, depression

Doctoring 2 topicsDoctoring 2 topics

• CellulitisCellulitis

• PharyngitisPharyngitis

• Smoking Cessation Smoking Cessation

• Breast Cancer #1 Breast Cancer #1

• Breast Cancer #2 Breast Cancer #2

• HypertensionHypertension

• Rape CaseRape Case

• Obesity, Nutrition, Obesity, Nutrition, ExerciseExercise

• Bioterrorism and Bioterrorism and Anxiety Anxiety

• Parkinson’s (Caregivers) Parkinson’s (Caregivers)

• Cardiac SimulatorCardiac Simulator

• Healer’s ArtHealer’s Art

• Formative OSCEs Formative OSCEs

• Hip fracturesHip fractures

• Prostate/BPHProstate/BPH

• Healer’s Art – Grief and Healer’s Art – Grief and LossLoss

Doctoring 2 – cont.Doctoring 2 – cont.

• Alcoholic PhysicianAlcoholic Physician• Breast Cancer Breast Cancer

(metastatic)(metastatic)• Prostate Cancer Prostate Cancer • Diabetes (foot and eye Diabetes (foot and eye

exam)exam)• Gastroenteritis Gastroenteritis

(interpreters) (interpreters) • Asthma and Asthma and

adolescent depressionadolescent depression• Asthma, suicideAsthma, suicide

• Breast Cancer end of Breast Cancer end of lifelife

• Back PainBack Pain• DementiaDementia• Abortion Abortion • Tension HA vs Tension HA vs

MigraineMigraine• Dermatology casesDermatology cases• MalpracticeMalpractice• Domestic ViolenceDomestic Violence

Doctoring 3 - IOMDoctoring 3 - IOM

• AsthmaAsthma• Health care CoordinationHealth care Coordination• Children with special Children with special

health care requirementshealth care requirements• DiabetesDiabetes• End of life care for patients End of life care for patients

with advanced organ with advanced organ system failuresystem failure

• Evidence based cancer Evidence based cancer teststests

• Elder careElder care• HypertensionHypertension• ImmunizationImmunization• Coronary Heart DiseaseCoronary Heart Disease

• Major DepressionMajor Depression• Medication ErrorsMedication Errors• Infections acquired in Infections acquired in

Hospitals Hospitals • ObesityObesity• Pain managementPain management• Pregnancy and ChildbirthPregnancy and Childbirth• Self management and Self management and

health literacy (focus on health literacy (focus on arthritis case)arthritis case)

• Mental IllnessMental Illness• StrokeStroke• Addiction and Substance Addiction and Substance

AbuseAbuse

Prostate ModuleProstate Module

• By the completion of the module, By the completion of the module, students will be able to:students will be able to:

• List the differential diagnosis of urinary List the differential diagnosis of urinary symptomssymptoms

• Describe aspects of benign prostatic Describe aspects of benign prostatic hyperplasia including:hyperplasia including:– Evidence-based medicine (EBM) approach to Evidence-based medicine (EBM) approach to

treatment using lifestyle changes, medicine, treatment using lifestyle changes, medicine, phytotherapy, surgeryphytotherapy, surgery

• Critically appraise evidence on the risks and Critically appraise evidence on the risks and benefits of preventive services such as PSAbenefits of preventive services such as PSA

Prostate Module ObjectivesProstate Module Objectives

• Discuss the value of the USPSTF and the Discuss the value of the USPSTF and the Cochrane database for systematic reviews Cochrane database for systematic reviews (EBM)(EBM)

• Describe the use and limitations of Describe the use and limitations of screening tests (using PSA as an example) screening tests (using PSA as an example)

• Describe the importance of “informed Describe the importance of “informed consent” surrounding issues of screeningconsent” surrounding issues of screening

• Describe lead-time and length-time bias Describe lead-time and length-time bias and their importance in evaluating the and their importance in evaluating the result of cancer screening studiesresult of cancer screening studies

Prostate SizeProstate Size

DESCRIPTION ANALOGY GRAMS

Small Walnut 15-20

mild enlargement ping pong ball 35-40

Moderate enlargement

Plum 50

severe enlargement can’t get finger over top 60+

PSAPSA

• DVD on screening with PSA - includes DVD on screening with PSA - includes interviews of 2 doctors considering interviews of 2 doctors considering having PSA screening having PSA screening

• Informed consentInformed consent

• Students learn about uncertainty in Students learn about uncertainty in medicinemedicine

SurgerySurgery

• TURPTURP (transurethral resection of the (transurethral resection of the prostate) prostate)

• TUIPTUIP (transurethral incision of the prostate) (transurethral incision of the prostate)

• TUMT TUMT Transurethral microwave Transurethral microwave thermotherapythermotherapy

• TUVPTUVP Transurethral vaporization of the Transurethral vaporization of the prostate prostate

• TUNATUNA Transurethral needle ablation Transurethral needle ablation

• Open ProstatectomyOpen Prostatectomy

Prostate Case – Part 2Prostate Case – Part 2

• Patient returns with elevated PSAPatient returns with elevated PSA

• Show students rectal ultrasound and Show students rectal ultrasound and biopsiesbiopsies

• Get pathology results with Gleason Get pathology results with Gleason ScoresScores

• Help patient decide on course of Help patient decide on course of actionaction

Dermatology CasesDermatology Cases

• On the web at:On the web at:

http://fm.mednet.ucla.edu/derm/search.cfhttp://fm.mednet.ucla.edu/derm/search.cfmm

Breast Cancer CaseBreast Cancer Case

• Patient presents with painful lumpPatient presents with painful lump

• Family History suggestive of genetic Family History suggestive of genetic breast cancerbreast cancer

• Normal mammogramNormal mammogram

• Suspicious ultrasoundSuspicious ultrasound

• Send for core needle biopsySend for core needle biopsy

Breast Cancer Case – Part 2Breast Cancer Case – Part 2

• Core needle biopsy result shows Core needle biopsy result shows invasive intraductal carcinomainvasive intraductal carcinoma

• Counseling of patient to talk about Counseling of patient to talk about where to go from herewhere to go from here

• Treatment optionsTreatment options

• Consider BRCA testingConsider BRCA testing

Questions?Questions?