ࡱ> { ?bjbjzz 8|\\8 D"%%%%& 14$&&&&&&$GJQA6&&A6A6J%%AAAA6~%%$AA6$AA}#D%Px:^0FM>DDA6A6AA6A6A6A6A6JJ@A6A6A6A6A6A6A6A6A6A6A6A6A6A6A6A6\ |:  FAMILY MEDICINE CLERKSHIP SYLLABUS UNIVERSITY OF LOUISVILLE DEPARTMENT OF FAMILY AND GERIATRIC MEDICINE SCHOOL OF MEDICINE 2013-2014 Donna M. Roberts, M.D. Course Director 852-5314  HYPERLINK "mailto:dmrobe01@louisville.edu" dmrobe01@louisville.edu Jeri R. Reid, M.D. Associate Course Director 852-5314  HYPERLINK "mailto:jrreid01@louisville.edu" jrreid01@louisville.edu Anne Loop Project Coordinator 852-5314  HYPERLINK "mailto:ajloop01@louisville.edu" ajloop01@louisville.edu Fax-852-7142 Lana Metzler Placements Coordinator 852-2707  HYPERLINK "mailto:llbeat01@louisville.edu" llbeat01@louisville.edu DFGM Main Office for emergencies only 852-5201 Syllabus prepared by Donna M. Roberts, MD, last updated June 13, 2013 Schedule/information presented in syllabus is subject to change. Students will be notified by RedMed Website and by Outlook email of changes. Credit Hours = 7.5 Prerequisite: Third Year Status TABLE OF CONTENTS  TOC \o "1-2" \u I. WELCOME  PAGEREF _Toc265677146 \h 3 II. INTRODUCTION  PAGEREF _Toc265677147 \h 3 AHEC  PAGEREF _Toc265677148 \h 3 III. EDUCATIONAL GOALS  PAGEREF _Toc265677149 \h 4 IV. LEARNING OBJECTIVES  PAGEREF _Toc265677150 \h 5 Principles of Family Medicine  PAGEREF _Toc265677151 \h 5 Clinical Experiences  PAGEREF _Toc265677152 \h 6 Table 1: Core Acute Presentations  PAGEREF _Toc265677153 \h 8 Table 2: Core Chronic Disease Presentations  PAGEREF _Toc265677154 \h 10 V. COURSE RESPONSIBILITES  PAGEREF _Toc265677155 \h 11 A. Clinical Experiences  PAGEREF _Toc265677156 \h 11 B. SOAP Notes  PAGEREF _Toc265677157 \h 11 C. Independent Learning Activities  PAGEREF _Toc265677158 \h 12 C. Group Learning Activities  PAGEREF _Toc265677159 \h 14 VI. ASSESSMENT 15 A. Mid-Clerkship Feedback 15 B. fmCases Quiz  PAGEREF _Toc265677163 \h 15 C. Final Exam  PAGEREF _Toc265677165 \h 15 D. Clinical Evaluations 16 E. Grading  PAGEREF _Toc265677167 \h 17 F. Honors  PAGEREF _Toc265677168 \h 17 VII. COURSE REQUIRMENTS 17 A. Evaluation 17 B. Patient Logs  PAGEREF _Toc265677171 \h 18 C. Attendance  PAGEREF _Toc265677172 \h 18 D. Assignments Checklist 18 VIII. LEARNING RESOURCES 20 A. REDMED 20 B. TEGRITY LECTURES  PAGEREF _Toc265677176 \h 20 C. ACCESSING REDMED  PAGEREF _Toc265677177 \h 20 D. TEXT  PAGEREF _Toc265677178 \h 20 IV. ADDITIONAL GUIDELINES FOR STUDENTS 20 A. DRESS CODE 20 B. EMAIL AND CONTACT METHOD 21 CLERKSHIP LOCATIONS 21 APPENDIX 1: CLINICAL AND TEACHING OPPORTUNITIES 22 APPENDIX 2 OME POLICIES 23  I. WELCOME Welcome to the Family Medicine Clerkship. This six-week rotation will enable medical students to understand the principles of family medicine and their application in community practice. Family Medicine, the one medical specialty that provides continuing and comprehensive medical care for individuals and families, integrates the biological, clinical and behavioral sciences in the care of the undifferentiated patient. Family Medicine differs from other specialties in that it encompasses all ages, both-genders, each organ system and every disease entity. Family Medicine provides first contact, ongoing, and preventive care. Family medicine clinical experiences allow students to understand how context influences the diagnostic process and management decisions. Students learn the fundamentals of an approach to the evaluation and management of frequently occurring, complex, concurrent, and ill-defined problems across a wide variety of acute and chronic presentations. II. INTRODUCTION Most of the students time in the clerkship will be spent caring for patients in ambulatory settings although students will have opportunities to work with physicians in the care of their hospital and nursing home patients. The clerkship places students with family physicians in approved AHEC locations throughout Kentucky. Students will also work with faculty and residents at residency training sites for the Department of Family and Geriatric Medicine (DFGM). Students will observe the family physicians interactions with sub-specialists and use of allied health professionals. The students will gain an appreciation of different skills required to manage patients in the outpatient setting and in the context of the family unit. Students will spend four weeks of the clerkship in a medically underserved area of Kentucky working with a family physician under the AHEC guidelines. The other two weeks will be spent in Clinical sites working with faculty and residents from the DFGM. AHEC The School of Medicine and the Department of Family and Geriatric Medicine are committed to providing medical training in areas away from the University Medical Center setting in conjunction with the Area Health Education Center Program (AHEC). This is a federal and state funded program. AHEC sites include offices of family physicians throughout the state of Kentucky. These physicians have gratis faculty appointments with the Department of Family and Geriatric Medicine. The Department of Family and Geriatric Medicine will place approximately 100 percent of its students in AHEC areas for the 2013-2014 academic year. Through experiencing medicine in communities throughout Kentucky, students will be able to more fully understand the role played by the Family Physician and other health care professionals in patient management. Students may receive a stipend to offset the cost of housing while at the AHEC site. If the student receives a stipend it must be turned over to the housing host before the rotation is completed. This check will be mailed from the University of Louisville controllers office to the students permanent address or electronically deposited. Learning resources Students will utilize the following resources to meet the learning objectives of the family medicine clerkship. Direct patient care in clinical settings Power Point Presentations on Tegrity Fm Cases Recommended Textbooks: Sloane PD. Essentials of family medicine. 6th ed. Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins; 2011. Lipsky MS, King MS. Blueprints family medicine. 3rd ed. Malden, Mass.: Blackwell; 2010. Toy EC, Briscoe DA, Britton B. Case files. Family medicine. 3rd ed. New York: McGraw-Hill Medical; 2012. A variety of assessment methods will be used to evaluate the students knowledge and skills. These include direct observation using the clinical evaluation forms and the standardized patient cases, the test on fm cases, and the NBME subject exam. III. EDUCATIONAL GOALS & Alignment with sOM PROGRAM OBJECTIVES The numeric references below refer to SOM program objectives. A list of the SOM program objectives can be found here:  HYPERLINK "http://louisville.edu/medschool/curriculum/objectives-for-the-medical-education-program.html" http://louisville.edu/medschool/curriculum/objectives-for-the-medical-education-program.html At the end of the Family medicine clerkship, each student should be able to: Discuss the principles of family medicine. [1.1], [1.7] Gather information, formulate differential diagnoses, and propose plans for the initial evaluation and management of patients with common presentations. [2.1 - 2.6], [3.1], [3.2], [3.5], [4.1], [4.2], [5.1] Manage follow-up visits with patients having one or more common chronic diseases. [4.3], [4.4], [4.5], [5.2], [5.4], [6.9], [7.5] Develop evidence-based health promotion/disease prevention plans for patients of any age or gender. [2.4], [8.5] Demonstrate competency in advanced elicitation of history, communication, physical examination and critical thinking skills. [4.1], [5.1], [6.1], [6.4] Write SOAP notes and give oral presentations in the appropriate format for the outpatient setting. [5.2], [6.2], [6.3] Participate in a community project to demonstrate greater knowledge of the AHEC community. [8.1], [8.3], [8.4] Utilize appropriate techniques to communicate with patients of all levels of health literacy. [6.1], [6.4], [6.9] Demonstrate a commitment to professionalism and continuous improvement. [1.2], [1.9], [1.10], [6.8] IV. LEARNING OBJECTIVES--SEE SEPARATE REDMED FOLDER The learning objectives for this clerkship are modified from the Society of Teachers of Family Medicine (STFM) Clerkship Curriculum Document developed by family medicine educators in 2009. Principles of Family Medicine Specific learning objectives have been developed that illustrate each of the five principles of family medicine: the biopyschosocial model, comprehensive care, continuity of care, contextual care, and coordination/ complexity of care. The Biopsychosocial Model - Patient-centered care that approaches patients with sensitivity and responsiveness to culture, age, gender, and disabilities and incorporates psychosocial, cultural and family data into management plans. At the end of the clerkship students should be able to: Demonstrate active listening skills and empathy for patients. Demonstrate the ability to elicit and attend to patients specific concerns. Explain history, physical exam and test results in a manner that the patient can understand. Use effective listening skills and empathy to improve patient adherence to medication and lifestyle changes. Discuss the influence of psychosocial factors on a patients ability to provide a history and carry out a treatment plan. Discuss mechanisms to improve adherence to and understanding of screening recommendations. Use the teachback method to enhance patient understanding. Provide patient education tools taking into account literacy and cultural factors. Comprehensive care - Care that attends to the acute, chronic, and preventive needs of patients and families in all phases of the life cycle. At the end of the clerkship the student should be able to: Formulate clinical questions important to patient management and conduct an appropriate literature search to answer clinical questions. Find and use high quality Internet sites as resources for use in caring for patients with core conditions. Continuity of care The promotion of continuous healing relationships by providing a personal medical home for patients and their families that facilitates ongoing care and access to appropriate consultants and providers. At the end of the clerkship the student should be able to: Describe the barriers to access and utilizing health care that stem from personal barriers. Contextual care - The development of treatment plans that are evidence-based and improve functional outcome and quality of life for patients. At the end of the clerkship the student should be able to: Demonstrate interpersonal and communication skills that result in effective information exchange between patients of all ages and their families Demonstrate the above skills that result in effective information exchange between patients and other healthcare providers. Communicate effectively with patients and families from diverse cultural backgrounds. Discuss areas where culture can impact the ability of patients to access and utilize health care. Coordination/complexity of care - The integration of complex care and the collaboration with other professionals that results in disease management, health promotion and patient education. At the end of the clerkship the student should be able to: Describe the value of teamwork in the care of primary care patients. Participate as an effective member of a clinical care team. Clinical Experiences In addition to the key principles of family medicine, there are several unique characteristics of family physicians that provide additional learning experiences for students. Family physicians usually have prior knowledge of their patients that allows for diagnostic testing and treatment to occur in stages that allows for more cost-effective and thoughtful care. Community-based physicians can take into account the prevalence of a disease in the outpatient setting to determine the appropriate course of action. Lastly, many family physicians use acute visits as opportunities to address chronic disease or health promotion issues. All students can benefit from learning how to provide care within this context. Acute Presentations The core acute presentations are listed in Table 1. At the end of the clerkship the student should be able to: Differentiate among common etiologies based on presenting symptom. Recognize dont miss conditions that may present with a particular symptom. Elicit a focused history and perform a focused physical examination. Discuss the importance of a cost-effective approach to the diagnostic work-up. Describe the initial management of common and dangerous diagnoses that present with a particular symptom. Chronic Presentations - The general approach to most chronic diseases includes diagnosis, surveillance, treatment, and shared goal-setting. Chronic disease management involves empowering patients to engage in their own care and work as a team member along with their health care professionals. Continuity with patients, provided in the family medicine setting, increases efficacy and improves outcomes. The core chronic diseases are listed in Table 2. At the end of the clerkship, for each chronic disease, the student should be able to: Find and apply diagnostic criteria. Find and apply surveillance strategies. Elicit a focused history that includes information about adherence, self-management, and barriers to care. Perform a focused physical examination that includes identification of complications. Assess improvement or progression of the disease. Propose an evidence-based treatment plan. Outline the role of nutrition in the management of chronic disease Document a chronic care visit. Communicate respectfully with patients who do not fully adhere to their treatment plan. Educate the patient about an aspect of their disease using the teach-back method. Health Promotion and Disease Prevention Family physicians provide preventive care during health promotion visits, during office visits for another purpose, and outside the office in other health care settings. It is important that preventive care be evidence-based, individualized to each patient depending on risk factors, current diseases, patient/parent preference and affordability. Attention to preventive care issues can be included in every office visit. At the end of the clerkship the student should be able to: Define primary, secondary, and tertiary prevention. Identify risks for specific illnesses that affect screening and treatment strategies. For women: elicit a full menstrual, gynecological, and obstetrical history. For men: identify issues and risks to sexual function and prostate health. For children and adolescents: elicit appropriate history to include immunization status, developmental milestones, and health risks. Find and apply the current guidelines for adult, adolescent and child immunizations. Provide appropriate anticipatory guidance to patient/parent. Communicate effectively with adults, children, teens and families. Table 1: Core Acute Presentations Topic CommonSeriousTopic-specific ObjectivesUpper respiratory symptomsInfectious: Viral URI, bacterial sinusitis, strep pharyngitis, otitis media, mononucleosis. Noninfectious: Allergic rhinitisEpiglottitis -Recognize that most symptoms are caused by viruses and dont require antibiotics. -Determine patients pretest probability for strep pharyngitis and make appropriate treatment decisionJoint pain and injury-Ankle sprains and fractures -Knee ligament and meniscal injuries -Shoulder dislocations and rotator cuff injuries -Hip pain -Carpal tunnel syndrome -Osteoarthritis -Overuse syndromes (Achilles tendonitis, patellofemoral syndrome, subacromial bursitis, rotator cuff tendinosis)-Septic arthritis -Acute compartment syndrome -Vascular compromise associated with fracture or dislocation-Perform an appropriate musculoskeletal examination -Apply Ottawa decision rules to determine the need for knee and ankle radiographsPregnancy (Initial presentation)-Intrauterine pregnancy-Ectopic pregnancy -Miscarriage-Recognize common presentations of pregnancy, including positive home pregnancy test, missed/late periods, and abnormal vaginal bleeding -List recommended lab testing for routine prenatal care.Abdominal pain-Gastroesophageal reflux disease -Gastritis -Gastroenteritis -Irritable bowel syndrome -Dyspepsia -Constipation -Functional-Appendicitis -Diverticulitis -Cholecystitis -Inflammatory bowel disease -Ectopic pregnancy -Peptic ulcer disease-Recognize the need for emergent versus non-urgent management for varying etiologies of abdominal painCommon skin lesions-Actinic keratosis -Seborrheic keratosis -Keratoacanthoma -Squamous cell carcinoma -Basal cell carcinoma -Warts -Inclusion cysts-Melanoma-Describe a skin lesion using appropriate medical terminology -Identify skin lesions from photographs and brief clinical descriptorsCommon skin rashes-Atopic dermatitis -Contact dermatitis -Scabies -Seborrheic dermatitis -UrticariaStevens-Johnson syndrome-Describe the characteristics of a rash -Identify rashes from photographs and brief clinical descriptors Abnormal vaginal bleeding-Anovulatory cycles -Polycystic ovarian syndrome -Perimenopausal/menopausal -Contraception effects-Miscarriage-Elicit an accurate menstrual history -Recognize when vaginal bleeding is abnormalLow back pain-Muscle strain -Altered body mechanics -Nerve root compression-Abdominal aneurysm rupture -Acute fracture -Spinal cord compromise -Bone metastases-Describe indications for plain radiographs for back pain -Conduct an appropriate musculoskeletal and focused neurological exam for back painCough-Infectious: Pneumonia, bronchitis, URI, sinusitis -Nonifectious: Asthma, GERD, allergic rhinitis-Lung cancer -Pneumonia -Tuberculosis-Describe the indications for chest Xray -Recognize pneumonia on a chest XrayChest pain-Gastrointestinal -Musculoskeletal -Cardiac -Pulmonary-Acute coronary syndrome -Pulmonary embolism -Pneumothorax-Recognize the indications for emergent vs. urgent vs. non-urgent management for chest pin -Recognize cardiac ischemia and injury on an electrocardiogramHeadache-Tension -Migraine -Sinus pressure-Meningitis -Subarachnoid hemorrhage -Temporal arteritis-Determine when imaging is indicatedVaginal discharge-Bacterial vaginosis -Vaginal candidiasis -Trichamoniasis -Cervicitis-Pelvic inflammatory diseaseEvaluate vaginal discharge: wet prep/KOH, pH, whiff testDysuria-Urethritis -Bacterial cystitis -Pyelonephritis -Prostatitis -Vaginitis/cervicitis-Interpret a urinalysisDizziness-Benign positional vertigo -Labyrinthitis -Orthostatic dizziness-Cerebrovascular disease -Brian tumor -Menieres diseaseShortness of breath/ wheezing-Asthma -Chronic obstructive pulmonary disease -Congestive heart failure -Angina -Obesity-Acute exacerbations of asthma or COPD -Pulmonary embolism -Pulmonary edema -pneumothorax -Acute coronary syndrome-Recognize typical radiographic findings of COPD and CHFFever-Viral URI -Strep pharyngitis -Influenza -Otitis media-Meningitis -Sepsis -Fever in the immunosuppressed patient-Describe a focused approach to diagnostic testing in patients with fever in all age groupsDepression (Initial presentation)Depression-Suicidal ideation-Use a validated screening tool for depression -Assess suicidal ideation and/or substance abuseMale urinary symptoms/prostate-Urethritis -Prostatitis BPH Erectile dysfunctionProstate carcinoma-Select appropriate laboratory tests for a male patient with urinary complaintsDementiaDementia Delerium-Perform a validated screening test for cognitive decline -Select appropriate diagnostic tests for a patient presenting with memory loss, focusing on treatable causesLeg swelling-Venous stasis -Medication-related edema -Deep venous thrombosis -Congestive heart failure-Recognize the need for urgent vs. nonurgent evaluation of leg swelling Table 2: Core Chronic Disease Presentations TopicTopic-specific ObjectivesMultiple chronic illnesses- Assess status of multiple diseases in a single visit. - List important criteria to consider when prioritizing next steps for management of patients with multiple uncontrolled chronic diseases. - Document an encounter with a patient who has multiple chronic diseases using a SOAP note and/or chronic disease flow sheet or template.Hypertension- Take an accurate manual blood pressure. - Recognize the signs/symptoms of end-organ disease.Type 2 diabetes mellitus- Perform a diabetic foot examination. - Document an encounter using a diabetes mellitus flow sheet or template.Asthma/chronic obstructive pulmonary disease (COPD)-Discuss the differences between asthma and COPD, including pathophysiology, clinical findings, and treatments. -Recognize an obstructive pattern on pulmonary function tests. - Discuss smoking cessation. Hyperlipidemia-Determine a patients cholesterol goals based on current guidelines and the individuals risk factors. -Interpret lipid laboratory measurementsAnxiety-Describe how an anxiety disorder can compromise the ability for self care, to function in society, and to cope effectively with other health problems.Arthritis-Guide a patient in setting goals for realistic control of pain and maximize function.Chronic back pain-Obtain a medication use history. - Anticipate the risk of narcotic-related adverse outcomes. -Guide a patient in setting goals for pain control and function.Coronary artery disease- Identify risk factors for coronary artery disease. - Use an evidence-based tool to calculate a patients coronary artery disease risk. - Counsel patients on strategies to reduce their cardiovascular risks.Obesity-Obtain a dietary history. - Collaborate with a patient to set a specific and appropriate weight loss goal.Heart failure (HF)- Recognize the signs/symptoms of HF. - Recognize signs of HF on a chest radiograph.Depression (previously diagnosed)-Assess suicide risk. - Describe the impact of depression on a patients ability for self care, function in society, and management of other health problems.Osteoporosis/osteopenia-Recommend preventive measuresSubstance use, dependence, and abuse-Obtain an accurate substance use history in a manner that enhances the student-patient relationship. -Differentiate among substance use, misuse, abuse, and dependence. - Communicate respectfully with all patients about their substance abuse. -Counsel a patient about tobacco cessationThyroid disordersOutline management plan for hypothyroidism. Outline evaluation of hyperthyroidism and thyroid nodules Students will acquire knowledge of the diagnosis and management of the acute and chronic illnesses through direct patient care and the use of the online fm Cases. Additional topics are covered in short Tegrity lectures on RedMed. V. COURSE RESPONSIBILITES A. Clinical Experiences The student will evaluate and write up a minimum of three patients per half day. The student may actually see more patients with the preceptor without doing complete evaluations on all patients seen. At times, other learning opportunities will arise in the clinical setting; students may participate in these activities as desired (i.e. if another resident or faculty member is doing a procedure and invites student to observe or assist). Students working with private practitioners may make hospital rounds, nursing home rounds, home visits and attend professional meetings with the preceptor. Students may be invited to speak to civic or school groups in the communities in which they work. The student will see the patient alone, obtain a pertinent history and perform the appropriate focused physical examination. Then the student will present the patient to the preceptor and an assessment of the problem and plan of management is determined. The student will write up the encounter in a SOAP note. Students will have their AHEC preceptor observe them with at least one patient and document the observed history and physical for submission to the clerkship faculty. The history and physical DOES NOT have to be comprehensive but should be focused to the patients reason for visit. Evaluation of clinical experiences will be Summative Evaluations from the AHEC preceptor and from the faculty and residents in the DFGM clinical sites. These evaluation forms are similar to those used on each of the required third year clerkships. The numerical scoring is also similar. The Summative Assessment of performance is completed by the preceptors at the end of the time spent at that site. Preceptors should provide formative feedback to you during the rotation and written comments with your evaluations. B. SOAP Notes It is expected that you will use this method when writing your notes. S: Subjective (history) O: Objective (exam) A: Assessment (problems) P: Plan The Subjective portion of the medical record should detail symptoms related by the patient, any pertinent past medical history, responses to both patient and physician initiated therapeutic maneuvers, and test results not seen by the physician. The Objective portion should detail the physician's findings on examination of the patient. This includes any findings on physical exam, laboratory tests, x-rays, endoscopies, stress tests or other procedural/laboratory work. Any findings by the resident or attending that the student could not reproduce need to be recorded here. The Assessment portion includes the physician's interpretation of the subjective and objective portions. Include a list of "possible" or "rule out" diagnoses to help orient your thinking or the thinking of other physicians for patient follow up. Do not rewrite the history and physical exam findings in the assessment. The Plan portion records the management plan for the patient. This includes medications (with dosage, number dispensed, and instructions to the patient concerning possible side effects), any procedural, laboratory or physical therapy scheduled, (include times and locations), and instructions for follow up. The preceptor, (residents or faculty members) must make a note in the chart. Be sure the preceptor has access to the chart after you complete your note. Some offices will have student notes written on separate pages since only the preceptors note is billable. See RedMed for SOAP note instructions. C. Chronic Disease Form and Patient Follow-up Students will complete and document follow-up on at least one patient with a chronic disease. Below is a list of the acceptable diagnoses. The Chronic Disease Document Sheet, distributed during orientation, should be completed when the patient is seen. The student will help the patient set a self-management goal and make contact with the patient later to assess his/her progress toward that goal. Self-management goals should be specific, attainable, and measurable. Examples are listed on the RedMed site. Acceptable diagnoses: Asthma: Intermittent Persistent (mild mod sev) Chronic kidney disease: Stage 1 2 3 4 5 Congestive heart failure: Class I IIa IIb III COPD: Stage I II III IV Dementia: MMSE score____ Diabetes: Type 1 2 Hyperlipidemia Hypertension: Stage 1 2 Tobacco Use D. Independent Learning Activities COMMUNITY PROJECT Community Experience outside the Physicians Office: The medical student will participate in an activity that exposes the student to an aspect of the community outside the physicians office while at the AHEC site The experience may be related to medical services or may involve another community group such as a civic or educational organization. Educational Objective: Student will acquire broader knowledge of the community in which he/she is working and the resources within that community. Examples of acceptable community experiences: Home Visit with physician or other health care provider Scheduled activity with clients at a Senior Day Center School presentationdoes not include simple Q&A at your high school Jail or prison health care with health care provider Civic group presentation Visit to substance abuse treatment facility with health care provider Hospice Home Visit with Hospice staff *Activity at a family members long term care facility is not acceptable Process: During week 1, the student will identify an area of interest for the project. The student should consult with the preceptor regarding opportunities that may be available through community activities. If an opportunity exists to work with the physician outside the office, the student may proceed with this project. If no opportunity is identified with the physician, it is the students responsibility to contact the regional AHEC coordinator to find another opportunity. Regional coordinators have identified other activities in many areas where students may complete this experience. These activities may be in surrounding areas up to one hour away. The student and the AHEC coordinator will review the options and the student will schedule the activity. Weeks 2-3 Student will schedule and execute the community experience. It is expected that if the student has a day off because the physician is not seeing patients on that day, this day will be used. In some instances the student will have to schedule a time out of the clinical practice to complete the activity. It is the students responsibility to inform the preceptor and office staff of the need to be away from the clinical practice. It is expected that this will take a maximum of four hours unless a long commute is involved. Student will write up the experience for submission to clerkship faculty at the end of the clerkship. The write-up needs to be to one page detailing the experience. If a handout was prepared for an independent presentation, it must also be submitted. Evaluation: Evaluation form to be completed by physician, AHEC regional coordinator, or other designated supervisor. 25 points Evaluation of students written submission by clerkship faculty. 25 points *Students with ongoing projects in the Louisville community may not submit this work for the required community project. Students from Louisville who return to their high schools for presentations may not submit this for the required community project. fmCASES Students must complete twelve required online cases from the fmCases during the clerkship. The web-based cases require students to work through the complete evaluation and management of common family medicine diagnoses. A list of the twelve required cases is included on RedMed. These cases have been chosen to supplement clinical experiences in some areas that may not always be covered extensively in the preceptors office. Students may elect to complete as many additional cases as they wish. The cases provide students an opportunity to work through the history and physical exam then formulate a differential diagnosis in much the same manner that is expected during this clerkship. The cases have links to appropriate references that may be helpful during all clerkships. Access to cases is through the website  HYPERLINK "http://www.med-u.org" www.med-u.org. Students use the UofL Cardmail ID to sign on then will be asked to create a password. There will be a quiz on the twelve required cases at the end of the clerkship. Nutrition---Food Frequency Questionnaire Students will complete a Food Frequency Questionnaire(FFQ) that allows them to record their dietary intake. Students will receive a report on their dietary choices. Studies show that when health care providers know more about their own choices they are better equipped to counsel patients on nutrition. This will be reviewed by Nancy Kuppersmith, RD, a DFGM faculty member. E. Group Learning Activities 1. Health Literacy Curriculum During orientation students will be introduced to the concept of health literacy and learn methods to identify patients with limited health literacy. The didactic session and interactive opportunity will allow students to practice using the teach-back method which will help them interact with patients in the clinical setting. 2.Standardized PatientsPractice CSE Students will have two cases with standardized patients. The cases are designed to evaluate the students skills in performance of a focused interview and physical exam appropriate to the outpatient setting, formulate an appropriate differential diagnosis and management plan, communicate effectively with the patient, and write up the encounter in the appropriate SOAP note format. The time schedule for these exams is exactly like the schedule for Step 2 Clinical Skills exam and is intended to help prepare students for this exam. One case will involve interviewing and providing management plans to the patient over the telephone. Students SOAP notes and videos will be reviewed by clerkship and OME faculty. An unsatisfactory performance in any area will require additional training with the faculty and a repeat of the experience. Unsatisfactory performance on the repeat will result in zero points being awarded for this activity. 3. Discussion of Ethics Topics Students will meet with faculty from the Division of Medical Humanism and Ethics for discussion of topics related to the posted readings. Students will submit a short paragraph about an event they witnessed, and faculty will choose topics for discussion. This will be scheduled on the last Thursday of the Clerkship. The expectations for this discussion are outlined below. Reading assignments are posted on RedMed. The students will first read this Introduction:  HYPERLINK "https://www.dropbox.com/s/1j6ny5cwvv3ui9o/Family%20Medicine%20Clerkship%20%E2%80%B9%20Clinical%20Ethics%20Session%20INTRO.doc" \t "_blank" https://www.dropbox.com/s/1j6ny5cwvv3ui9o/Family%20Medicine%20Clerkship%20%E2%80%B9%20Clinical%20Ethics%20Session%20INTRO.doc Then read the three book chapters from the Sugarman Book  HYPERLINK "https://www.dropbox.com/s/kjwe1i5xifyc30p/Ethics%20in%20Primary%20Care.pdf" \t "_blank" https://www.dropbox.com/s/kjwe1i5xifyc30p/Ethics%20in%20Primary%20Care.pdf and then read the two publications relevant to the subject matter:  HYPERLINK "https://www.dropbox.com/s/w541g3pardwbqdu/BrettMcCullough.pdf" \t "_blank" https://www.dropbox.com/s/w541g3pardwbqdu/BrettMcCullough.pdf  HYPERLINK "https://www.dropbox.com/s/e19724ybg6xyy4l/Roadmap_web_version.pdf" \t "_blank" https://www.dropbox.com/s/e19724ybg6xyy4l/Roadmap_web_version.pdf VI. ASSESSMENT A. Mid-Clerkship Feedback This is a formative assessment for which you will not receive a numerical grade; however completion is required and is worth 10 points. One form is to be completed by you and e-mailed to Dr. Roberts and Dr. Reid halfway through the AHEC rotation. The form is available on RedMed under Evals and Testing. The second form requires your preceptor to observe you performing a focused history and focused physical exam on a patient during the rotation. This form must be faxed to Anne Loop at the halfway point of the rotation. This form is provided during orientation. You will also be required to submit your patient encounter log for review at this time. You will call Dr. Roberts or Dr. Reid to discuss your progress at this time. During orientation you must sign up a time for you to call the faculty. Be prepared to outline your specific goals or learning objectives for the remainder of the rotation. B. fmCases Quiz A quiz on the twelve required fmCases will be administered on the final Thursday of the clerkship. Students will have an opportunity to review the questions after the exam. These questions will be selected from a bank of questions prepared by the case authors. Students will have to repeat the quiz if they earn a score below 70%. If they earn blow 70% on the retake, they will be awarded 0 points. Challenge of Exam questions must be submitted within 48 hours of the exam in writing with at least 2 current references to support the challenge. The faculty will review and respond to the student. C. Final Exam The final written exam is the NBME Subject Exam in Family Medicine. . Students must attain a minimum raw score that corresponds to the fourth percentile, adjusted by quarters, on the Subject Exam to pass the clerkship. If there is no raw score that corresponds to the 4th percentile, the percentile ranking just below will be used. This raw score will be converted to a percentage score for purposes of calculating clerkship grades. A minimum raw score at the 75th percentile, adjusted by quarters, on the NBME shelf exam, in addition to exemplary performance in all areas of the clerkship, is needed for a student to receive the grade of HONORS. If there is no raw score that corresponds to the 75th percentile, the percentile ranking just below will be used. D. Clinical Evaluations Preceptors at the AHEC sites will complete a summative evaluation of the students performance. These forms should be given to the preceptor during the final week at the site and returned to Anne Loop at the end of the rotation. Faculty and residents at the DFGM clinical sites will complete a summative evaluation of each students performance. The faculty and residents will compile these evaluations during the monthly site meetings. The clerkship director has the ability to comment on any students performance even if he/she does not directly work with the student. Comments will be submitted to Student Affairs. Failure in any overall component on the summative evaluation i.e. knowledge, skills or attitude will result in a failing clinical score. Copies of these forms, which are a part of the Uniform Evaluation Project, will be distributed at orientation and are available on RedMed. E. Grading There are a total of 1000 points possible. The following factors will determine the final grade for the clerkship: Clinical Components Summative Evaluation from AHEC preceptor 320 points Observed Hx & PE 10 points Summative Evaluations from DFGM Clinical Sites.150 points Chronic Disease Documentation Sheet...................... 10 points Examination Components Successful Standardized Patient Exams 50 points Final Written Exam 300 points fmCases quiz 100 points Additional Components Community Project 50 points NutritionFFQ.. 10 points F. Honors HONORS for the clerkship will be given to students with 930 points or more. Students must achieve a raw score at the 75th percentile, adjusted per quarter, on the NBME Subject exam in family medicine in addition to exemplary performance in all other areas of the clerkship to receive HONORS.** Students must pass all components of the clerkship with a minimum score of 70%. Failure to pass any one of the three clinical components with a minimum score of 70% will result in an automatic failure for the entire clerkship. Deferred grades will be given to any student who failed the NBME Subject exam if there are no other NBME exam failures during the academic year. Remediation will be determined by the faculty following guidelines adopted by the EPC at the completion of the students academic year. The Clerkship director or department faculty reserves the right not to award honors if the student demonstrates a deficiency in any core competency (patient care, medical knowledge, interpersonal and communication skills, systems-based practice, practice-based learning and improvement, professionalism) regardless of numerical score. In addition, they reserve the right to fail a student regardless of numerical score. The observed History and Physical Exam form, as part of the Midclerkship assessment, must be turned in halfway through the clerkship for credit. Forms received more than 3 days after the due date will not be accepted. The FFQ must be completed by 5PM on Monday of week 5 in order to receive credit for the assignment. Any required forms received more than 3 days after the due date will not be accepted. Students who miss any written exam or the standardized patient exam must provide documentation for the absence in the form of doctors note or documentation of attendance at a ULSOM sanctioned activity. VII. COURSE REQUIRMENTS A. Evaluation Summative Evaluations from DFGM Faculty and Residents Summative Evaluation from AHEC preceptor Evaluation of community project Successful Completion of the Standardized Patient Exams Final Written Examination-NBME Subject Exam in Family Medicine Observed Hx & PE fmQuiz Chronic Disease Documentation Sheet Nutrition--FFQ B. Patient Logs Patient Encounters: Students are required to keep track of patient encounters using RedMed (https://redmed.louisville.edu). Students are required to document ALL patient encounters that you see and evaluate independently. DO NOT document patient encounters where you shadow the physician. There is a list of required diagnoses (posted on RedMed and provided separately) which must be seen during the clerkship. These must be documented as part of your patient encounter log. Be sure to review your patient encounter log at the time of your mid-clerkship assessment. You will be asked to report the status of your progress for seeing the required diagnoses and number of patients for each of them when you are contacted by the director or associate director of the clerkship. C. Attendance Attendance At All Scheduled Functions is Mandatory Attendance at Orientation is Mandatory The schedule for clinical experiences will be set by the preceptors with whom the student is assigned to work. If you have an emergency that prohibits you from attending a clinical session, your preceptor may arrange for you to make up this time. It is your responsibility to notify the preceptor and Anne Loop (852-5314) if you have to be absent. This is a clinical rotation. The AHEC preceptors may not observe the same holiday schedule as the University. You will be expected to follow the preceptors schedule. Students must attend all sessions at the beginning and the end of the clerkship; this includes an orientation on day one and a debriefing session after the final exams. Students are required to attend DFGM Grand Rounds on Fridays while in Louisville except on the day of the final exam. These are usually held in the Bottigheimer Auditorium at Jewish Hospital beginning at 7:30. Be sure to sign in outside the door. When the University cancels classes because of bad weather, third and fourth year students are encouraged to follow their regular schedule. If the UofL family medicine clinics are closed due to bad weather, the Clerkship director or coordinator, will contact the track captain and will email the track advising of the closure. D. Assignments Checklist ASSIGNMENT CHECKLIST GROUP A (AHEC Site first) _____Week 1: Identify a Community Project and work on fmCases _____Week 2: E-Mail Student Self-Assessment part of Mid-Rotation Feedback form to  HYPERLINK "mailto:dmrobe01@louisville.edu" dmrobe01@louisville.edu and  HYPERLINK "mailto:jrreid01@louisville.edu" jrreid01@louisville.edu _____Week 2: Have preceptor fax Preceptors Mid-Rotation Feedback form to Anne Loop at 502-852-7142 _____ Week 2: Call Dr. Roberts at 502-852-1993 or Dr. Reid at 502-852-0283 for mid- rotation consultation during your assigned time _____ Week 3: Work on Community Project and fmCases _____ Week 4: Thursday Give Summative Evaluation form to AHEC preceptor to complete. Work on fmCases _____ Week 5: MondayStandardized Patient Exams-Practice CSE; _____ Week 5: Monday---FamCram 12-1:00 (Bring your own lunch) _____ Week 5: MondayNutrition FFQ must be completed by 5 PM in RedMed ______Week 5: Follow schedule and work on fmCases _____ Week 6: Thursday 9:00 AM fmCases Quiz _____ Week 6: Thursday11:00-12:00 noon Ethics SessionBe sure to have read the Ethics readings on RedMed and bring your written paper to class today ______Week 6: Thursday12:00-1:00 PM FamCram _____ Week 6: Friday --9:00 AM Written Exam and Debriefing (Bring AHEC summative form, clinic summative form, & community project write up & evaluation.) ASSIGNMENT CHECKLIST GROUP L (Louisville site first) _____ Week 1: Follow schedule provided. Work on fmCases. _____ Week 2: Monday Standardized Patient Exams- Practice CSE. _____ Week 2: MondayFamCram 12:00-1:00 PM (Bring your own lunch) _____ Week 3: Identify a Community Project and work on fmCases _____ Week 4: Email Student Self-Assessment part of Mid-Rotation Feedback form to  HYPERLINK "mailto:dmrobe01@louisville.edu" dmrobe01@louisville.edu and  HYPERLINK "mailto:jrreid01@louisville.edu" jrreid01@louisville.edu _____ Week 4: Have preceptor fax Preceptors Mid-Rotation Feedback form to Anne Loop at 502-852-7142 _____ Week 4: Call Dr. Roberts at 502-852-1993 or Dr. Reid at 502-852-0283 for mid- rotation consultation at your assigned time. _____ Week 5: Monday---Nutrition FFQ must be completed by 5 PM in RedMed _____ Week 5: Work on Community Project and fmCases _____ Week 6: TuesdayGive Summative Evaluation form to AHEC preceptor to complete. _____ Week 6: Wednesday Leave AHEC site in time to arrive in Louisville by 3 PM _____ Week 6: Thursday -- 9:00 AM fmCases Quiz _____ Week 6: Thursday11:00-12:00 noon Ethics SessionBe sure to have read the Ethics readings on RedMed and bring your written paper to class today _____ Week 6: Thursday12:00-1:00 PM FamCram _____ Week 6: Friday9:00 AM Written Exam and Debriefing (Bring AHEC Summative form, clinic summative form, & community project write up & evaluation) VIII. LEARNING RESOURCES A. REDMED RedMed is a web-based course management program that the clerkship uses to make materials and forms available to students. The course learning objectives are posted on the RedMed Website. B. TEGRITY LECTURES Mini-lectures by DFGM faculty members on common problems are posted on Tegrity. The goal of these lectures is to provide the basics needed to approach these problems in the outpatient setting. Further reading is required for more extensive coverage of the topics. The faculty strongly recommends that each student review the Sports Medicine presentation on knee and shoulder exam and the Geriatrics presentations on Polypharmacy and Physiology of Aging. C. ACCESSING REDMED The Family Medicine Clerkship will be using the Internet to distribute course information to you. On the web site you will find schedule information, course syllabus, presentation handouts, additional reading assignments and contact information. We encourage you to check the site regularly for updated handout material and announcements regarding clerkship activities. The Family Medicine Clerkship RedMed page can be accessed at  HYPERLINK "https://redmed.louisville.edu" https://redmed.louisville.edu, using your ULink ID and password. After logging in, search for Family Medicine (without quotes) in the Find Your Courses field. This will bring you to the Family Medicine Clerkship page. If you have any problems with the system, please contact Amy Kiper at 852-8696 or by email at adkipe01@louisville.edu. D. TEXT The recommended texts for this clerkship are Essentials of Family Medicine, 6th Edition, Blueprints Family Medicine, 3rd Edition, Case Files in Family Medicine. Supplemental readings are posted with the learning objectives. IV. ADDITIONAL GUIDELINES FOR STUDENTS A. DRESS CODE Students must wear appropriate professional attire and white coat at all clinical sessions. Student appearance should reflect both personal values and the professionalism of the UofL School of Medicine. As such, professional decorum is expected. Since students will be meeting many new people in diverse situations, nameplates or badges for identification are encouraged. White coats with names should be available at all times and used as directed by each preceptor or agency personnel. Business dress (shirts and ties; dresses or suits) is expected. Blue jeans, shorts, T-shirts, sweats, scrubs, etc. are NOT acceptable. Some clinical sites require closed shoes for safety. Check with attending or staff at site. Students may wear casual attire (NO SCRUBS) on the days of written exams. During orientation we will take a photo which will be posted at each clinical site for easier identification. Take this to the office and ask the office manager where to place your photo. B. EMAIL AND CONTACT METHOD Students must have a cell phone number recorded at the clerkship office. The Clerkship Faculty and Staff will communicate with students using the Cardmail e-mail address or cell phone. Please provide our staff with any updated phone numbers during orientation. CLERKSHIP LOCATIONS U of L Family Medicine Newburg 1941 Bishop Lane, Suite 900 Louisville, KY 40218 (502) 852-6684 Contact: Jeri Reid, MD Directions: Take I-65 south to Watterson Expressway east to Newburg road. Take exit 15 to merge onto Newburg Road. At second stoplight turn left onto Goldsmith Lane. At next street, turn left onto Leith Lane. At end of Leith Lane, turn left onto Bishop Lane. 1941 Bishop Lane is a nine story building on the right. U of L Family Medicine Cardinal 215 Central Avenue; Ste. 100 Louisville, KY 40208 (502) 852-2822 Contact: Renee Girdler MD Directions: Take 1-65 south to Crittenden Drive. Go south, turn right at first light on Central Avenue. Cross Denny Crum Bridge. Entrance to facility is on right. Do not park at the front entrance. Students are required to park in the same area as Faculty and staff. Parking at the front door is for patients only. Center for Primary Care Cardinal 215 Central Avenue, Ste. 205 Louisville, KY 40208 (502)852-5201 Contact: Kathryn Schat, MD Directions: See above Grand Rounds 7:30 AM Friday mornings---Be sure to sign in Jewish Hospital Bottigheimer AuditoriumFirst Floor near Chestnut Street Entrance APPENDIX 1: CLINICAL AND TEACHING OPPORTUNITIES These are additional clinical or teaching opportunities available on the Family Medicine Clerkship. If you are interested in participating in one of these during the weeks that you are in Louisville, contact us and we will arrange it. Each activity is limited to one student each day. UL DFGM Hospital Inpatient Service: Student may make hospital rounds with the team any day of the week. Arrangements must be made by contacting the resident or attending in charge of the service. Delivery of baby with family medicine resident. Must notify the resident that you want to be called when patient presents to L&D Overnight in-house call for admissions and labor and delivery triage for family medicine OB patients. Student must arrange with on call resident. May do this from 5-10pm or all night. Home visits. Must be arranged with resident or faculty. OK to do with AHEC preceptor. TAPP (Teen Age Parenting Program) Faculty and residents provide prenatal and pediatric care to these patients at the schools during the academic year. Not available during the summer months. South Park TAPP site, Wednesday, and Thursday AM. Westport TAPP Tuesday AM. Make arrangements with the faculty member assigned. Nursing home patient care with family medicine resident, Thursday pm. Make arrangements with resident assigned to go that week. Sports medicine opportunities after hours with Dr.Jon Becker or Dr. Jessica Stumbo. APPENDIX 2 OME POLICIES SOM Policies For information on the following important School of Medicine policies and procedures, visit the Office of Medical Education's RedMed course site, available by clicking the drop-down arrow next to Favorites in the top left hand corner of the main RedMed calendar page. Choose courses, then in the Search A Course box, type OME inside the box. RedMed can be accessed at  HYPERLINK "https://redmed.louisville.edu" https://redmed.louisville.edu. - Mistreatment Policy - Preclinical and Clinical Absence Policies - Preclinical and Clinical Grading and Honors Policies - Policy regarding course evaluation and a link to online course evaluation system Continuity of Instruction Policy All medical students are urged to sign up for the UofL mobile phone emergency information system, RAVE (https://www.getrave.com/login/louisville), which provides real time text communications about any emergencies or long-term catastrophes. In the event that this clerkship is no longer able to meet face-to-face, students should immediately logon to the RedMed course website, where the clerkship director or his or her designee will provide instructions for adjustments to the meeting schedule, delivery of instruction, assignments, or examinations and deadlines. Students are asked to check the RedMed site regularly throughout the interruption of instruction for updates. The clerkship director will also use email to communicate regularly with students. In the event that students as a whole do not have access to the internet, alternative approaches to communicating with students will be arranged. However, should this occur, students should, depending upon their individual circumstances, make every effort to stay current with clerkship assignments/readings. In the event that a student is unable to attend class for an extended period of time, he or she should contact the clerkship director to discuss alternative means of fulfilling the clerkship requirements. Online Course and Clerkship Evaluations Effective July 1, 2002, the U of L School of Medicine requires all students to complete online evaluations for all required courses and clerkships. The Educational Policy Committee (EPC) has endorsed this online course evaluation process (May, 2002). The Office of Medical Education (OME) expects all students to submit online course and clerkship evaluations as part of the School of Medicines program-wide evaluation system. Bad Weather Policy for SOM Courses/Clerkships Clerkships: When the University delays or cancels classes, third and fourth year students shall follow their regular schedules unless otherwise specified by the clerkship director. Student Use of Electronic Medical Records The following rules apply to student use of electronic medical records: Students should be able to access electronic medical records using their own personal login information. Students should be able to enter a full note including history of presenting illness, past medical history (including surgeries, family history, etc.), review of systems, physical exam, laboratory/imaging data, and assessment and plan. Student notes should become a permanent part of the patient record. Students should be able to view all patient notes, labs, radiology reports, pathology reports and images. Students should have the ability to create orders. All student orders must be signed by a resident or attending physician. A preceptor should be able to view the students note and sign it. Faculty members must review student notes to ensure accuracy and appropriateness and provide feedback to students. APPENDIX 3: Clinical Absences Policy Absences Policy: Clinical Effective September 11, 2012 EPC approved 09/11/12 An essential element of a medical student's professional development is the consistent demonstration of a mature sense of dependability and accountability. Therefore, students are expected to be present and on time for all scheduled examinations, clinical assignments, and mandatory academic activities (e.g. Didactics, Standardized Patient interactions, Grand Rounds, Journal Club, M&M, etc.) unless the responsible faculty/staff grants an excused absence. The responsible faculty/staff are the leaders of the clerkship (i.e. the clerkship director, the clerkship coordinator, and site supervisors). Excused Absencesinstructions for students and absence criteria: 1. Requests for an excused absence should be made in writing, via email, to the clerkship director/coordinator and copy (Cc) the Medical Student Affairs email account (medstuaf@louisville.edu ) at the time of the request. 2. Anticipated absence requests related to University-sanctioned events must occur in writing at a minimum of one week prior to the event or activity. The faculty member will respond in writing (email) that approval has been granted. A university sanctioned event or activity shall be one in which a student represents the university to external constituencies in academic or extra-curricular activities. o Examples include an authorized presentation of scholarly work at an academic conference, serving as an official representative of the university, or participating in university-sanctioned events. http://louisville.edu/provost/what-we-do/classroom-policies/classroom-policies.html#excusedabsences 3. Regarding other anticipated absence requests, not related to University-sanctioned events, must occur in writing at least 30 days prior to the absence. A decision will occur within 7 working days of receiving the request, and the student will be notified via email. o Requests must fulfill one of the following criteria: A medical illness with written documentation supporting the inability to attend required educational activities that accounts for each day missed. An anticipated significant family event that requires the student s attendance. (NOTE: Weddings are generally NOT an excused absence) A family crisis that requires the student s presence. An anticipated religious ceremony or observation that is not an official University holiday (see U of L website for list of work-restricted religious holidays). http://louisville.edu/diversity/resources/Work-Restricted%20HolyDays2011-2012.doc Unforeseen documentable extenuating circumstances beyond the student's control. Absence for military service obligations. 4. Students requesting an absence must explain, in writing, the reason for the request (as well as cite one of the above circumstances in the written request). All requests will be centrally tracked by the Office of Medical Student Affairs via email communications between students and responsible faculty/staff. Proof of reason for absence (doctor note, meeting program, etc.) must be turned into the clerkship director / clinical coordinator. Responsible faculty/staff will judge all incurred absences or anticipated absence requests for graded learning activities. If an excused absence is granted by the clerkship director, the student is required to work out terms with the clerkship director and/or coordinator for rescheduling, make up, or waiving the missed assignments and points. When flexibility in scheduling within an existing block of time exists to accommodate the students request (e.g. call night) the decision to reschedule the student (versus consider the missed date an absence and withhold credit) is at the discretion of the affected clerkship director, staff, and related facilities. Unanticipated Absences Absences or tardiness for a scheduled academic assignment (shelf exam, mandatory class/student assembly, small group session, SP exam, clinical assignment, etc.) due to a personal illness, or an unanticipated crisis, are to be reported as soon as possible to the responsible faculty or staff memberthe course director(s) and coordinator, the site supervisors. In case of emergency, with limited time for notification, the clinical site should be notified or you can call the Office of Medical Student Affairs at (502) 852-5192 or send a detailed e-mail to medstuaf@louisville.edu ). Any verbal communication must be followed up with written communication from the student to the clerkship director, coordinator, and Office of Medical Student Affairs staff explaining the reason for absence. Students missing more than 48 hours of school due to an illness will be required to have a doctors statement. Students missing more than 48 hours of school must also notify the Office of Medical Student Affairs so that planning for a possible leave of absence can occur. Unexcused Absences Any student who is absent from an academic assignment, and has not been granted an excused absence by responsible faculty/staff, will receive an unexcused absence; and the student will receive a ZERO %&'      ! 1 9 : ; N e g h  ꧐ȉ~vnhhp*5hhW5hQN hhp_ hhKm hA/,hh$h0J hhhjhU hh> hOhp_ hWhWhh>5hhW5 h[geh[geh? hDoh[geh> hDoh> hpch[gehpc)%&'@l    : $a$gdgd$a$gd. - . 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