MDCN 330 & 430 Preceptor Information

All students will apply relevant office practice communication and history taking skills identified in the Communications 1 Course. Skills include introducing self to the patient, identification of presenting complaint(s) and eliciting further relevant pertinent positive or negative information to help with assessment; expected only if related course work has been completed. Skilled history taking will enquire and document psychosocial contexts (patient feelings, ideas, fears and expectations) and environmental circumstances, for example poverty, low literacy or lack of supports.

Use of open and closed questions, attentive listening, recognition of verbal and non-verbal cues, avoidance of jargon and clarification are applicable process skills to apply.

In Clinic:
To help with time management, chat with student/preceptor about expectations and time available to take the history prior to seeing patients.
History taking may be independent. If the student and preceptor initially choose to take histories together it is expected that this rapidly progresses to independent history taking with subsequent preceptor discussion. Preceptors and students may discuss the patient context prior to the visit; students may review medical records and related references before or after the visit. Students may accompany the preceptor in the exam room and participate in history taking, examinations, and discussions about diagnoses and planning. Students may present the history.

S Subjective
O Objective
A Assessment
P Plan

Document relevant history in Subjective.

What is HEARD?
Document the presenting complaint(s), history of presenting complaint(s) and answers to additional queries regarding pertinent positive and negatives as well as enquiry using a biopsychosocial approach to care- feelings, ideas, fears and expectations (FIFE) and social contexts, for example low literacy, poverty or abusive environments. With increasing skill students will organize by issue and prioritize issues.
Document relevant physical exam findings, vital signs, lab and diagnostics in Objective.

What is SEEN?
Ensure no history is recorded in objective.

Document what you think is going on in Assessment.

Document what your course of action is to address each issue in Plan.

Both A and P are informed by Subjective and Objective findings. At this early learner level preceptors most likely will have to make clinical reasoning overt to help learners understand how and why diagnoses and plans are developed.

Courses completed by end of MDCN 330 include Blood/GI, MSK/Derm, Well Physician, Ethics, and Global Health. Communications and Physical Exam courses are on-going.
Where relevant demonstrate a biopsychosocial approach to patient care. Consider use of PMH care providers. Consider when to return and why (continuity).
In clinic:

Review expectations that 2 SOAP notes are to be completed with preceptor review and feedback, one at the first clinic and another at the second clinic. SOAP notes without patient identifying data can be sent electronically if time is tight.
All physical examinations done by students must be with in-room preceptor/ resident or staff guidance and patient consent.

All students, whether in the rural stream or urban stream must complete two SOAP notes with preceptor review and feedback by mid-ITER evaluation and an additional 2 SOAP notes with preceptor review and feedback by the final-ITER.

Watch the video “The Patient’s Medical Home (PMH), the vision for Family Practice in Canada” at orientation or the link below:

The Patient's Medical Home (PMH), the vision of Family Practice in Canada

Awareness may be demonstrated by including use of PMH health team members in SOAP plans.

As students are placed into Patient’s Medical Home clinics, awareness may include discussions with preceptors about the PMH model of care, what makes a clinic a PMH and any consideration of the 10 pillars- patient-centered care, personal Family Physician, team-based care, timely access, comprehensive care, continuity of care, electronic records and health information; education, training and research; evaluation and quality improvement, and internal and external supports.

Generalists are a specific set of physicians whose core abilities are characterized by broad practice. The Praxis of Generalism in Family Medicine involves the core concepts of Comprehensive care, Complexity, Context, Continuity of care, Collaboration, and Communication. These concepts will be both discussed and modelled in the Orientation session, Small Groups, and Patient Medical Homes where you will have your clinical experiences.

Students will apply relevant communication skills and take a focused history based upon the reason for the patient visit.

Communication skills include introducing self, use of open questions then more specific closed questions, attentive listening, recognition of verbal and non-verbal cues, avoidance of jargon and clarification.

Focused history- taking includes identifying the reason for the visit (presenting complaint), and subsequent enquiry relevant to the presenting complaint.

History often requires attention to psychosocial contexts (patient feelings, ideas, fears and expectations) and environmental contexts, for instance: unsafe living situations, financial difficulty, or lack of transportation. Care plans developed without regard to patient contexts are less likely to be effective or followed.

Documentation of subjective, the history organized by issue; and objective, focused exam findings or results on file relevant to the presenting complaint, is reviewed and expected.

Based upon the history and identifying relevant positives and negatives, and as more course work is completed, students will develop increasingly accurate assessments and plans.
Preceptor student discussion is expected to help make clinical reasoning overt.

S Subjective             hear/history
O Objective              see/examine
A Assessment          what you think is going on if not sure, list most likely first
P Plan                       for each condition or diagnosis what will you do?

RAPRIO is a useful way to organize thinking to develop a plan. 

Reassure
Advise
Prescribe
Refer
Investigate
Observe                                                          

Consider

• Reassure, advise, prescribe, refer, investigate, observe
• Use of PMH team members
• Addressed patient bio-psycho-social contexts?
• When and Why to return to care?
• Prevention 

The Patient’s Medical Home (PMH), the vision for Family Practice in Canada, identifies 10 pillars that turn a clinic into a Patient’s Medical Home (Patient's Medical Home Vision). These are: patient-centered care; having a personal family physician; team-based care; timely access; comprehensive care; continuity of care; electronic records and health information; education, training and research; evaluation and quality improvement; and internal and external supports.

Generalists are a specific set of physicians whose core abilities are characterized by broad practice. The Praxis of Generalism in Family Medicine involves the core concepts of Comprehensive care, Complexity, Context, Continuity of care, Collaboration, and Communication. These concepts will be both discussed and modelled in the Orientation session, Small Groups, and Patient Medical Homes where you will have your clinical experiences.