COMP2 UNIT MEDICINE FOR OLDER PEOPLE, DERMATOLOGY, PRIMARY CARE Block 3, 2013-14 University of Bristol Medical School MB ChB: Year 4
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COMP2 UNIT
MEDICINE FOR OLDER PEOPLE, DERMATOLOGY, PRIMARY CARE
Block 3, 2013-14
University of Bristol Medical School MB ChB: Year 4
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WELCOME/OVERVIEW This handbook should be read in conjunction with the Year 4 Handbook and the Rules, Policies and Procedures Handbook.
Welcome to Community Orientated Medical Practice 2 (COMP2)! This handbook should be read in conjunction with the 3 study guides for COMP2. Over the following 9 weeks you will have the opportunity to learn about three different areas of clinical practice with strong links. We hope this course will prepare you for managing the range of patient-centred problems presenting in Primary Health Care, Dermatology and Medicine for Older People. Your learning in this unit will take place in different locations to give you a range of experiences.
The common learning threads running through this unit include:
Acute and chronic disease management
Patient self-management
Disease prevention
Primary and secondary care interface working
Team work and inter-professional learning
Record-keeping The vertical themes of consultation and procedural skills (CAPS), whole person care, therapeutics, disability and evidence-based medicine are also represented.
You will be learning to:
Formulate appropriate differential diagnoses and investigations
Communicate effectively with patients and carers
Develop a research-based approach to decision-making
Develop your written and presentation skills
Appreciate the roles of different health professionals and effective team work
Understand how the health services are organised in the UK
3
CONTENTS
Welcome/Overview
2
Contents
3
Key Dates: Structure of the Course, Timetables & Deadlines Overview of Course Timetable for Week 1 Timetable for Week 9 Important Dates & Deadlines COMP 2 Course Dates
4 4 5 6 7 8
Staff Information
9
Teaching Information: The Clinical Attachments
- Primary Health Care - Dermatology - Medicine for Older People
Aims And Objectives Learning Outcomes: - Primary Care & Core Problems - Dermatology & Core Problems - Medicine for Older People & Core Problems Professional Behaviour Teaching Information and Expected Student Input - Patients and Carers - On-Take & Out-of-Hours Commitments - Self-Directed Learning - Blackboard - Useful Websites Recommended Reading Assessment Information - Dates of Exams Seminar on Disability Assessments Blueprint Feedback
11 13 14 16 18 19 21 25 26 27 27 27 28 29 30 31 33 34
Travel 35
Additional Unit Information: Distinctions, Merits and Prizes Student Advice and Support Reporting a Critical Incident Illness and Unplanned Absence Planned Leave Accommodation/Residential Attachments Tutorial Support Professional Indemnity Student Health and Safety Medical Student Dress Code for Clinical Areas
36 37 37 38 38 39 39 39 39 40
4
KEY DATES
STRUCTURE OF THE COURSE, TIMETABLES & DEADLINES The 9-week course begins and ends with 2 and 3 days of plenary teaching in Bristol. Between these weeks are the clinical attachments. Each student will have an individual timetable. You will spend an equal time on your Primary Care and Medicine for Older People attachments. Half of you will do the Medicine for Older People attachment first and half will do your GP attachments first. Most of your will spend 4 weeks at a single GP practice but some of you will have this attachment split between 2 practices. Throughout the course you will be invited to attend Dermatology clinics and tutorials. You will allocate time for your student selected components throughout the 9 weeks. Please check your e-mail and the COMP2 Blackboard every day for up-to-date information on the course. Unfortunately it is not possible to allocate Wednesday afternoons for sport; there is simply not enough time or flexibility in the clinical attachments to allow for this.
TIMETABLES
Overview of course
Weeks 1 M/T
1 W/T/F
2 ALL
3 ALL
4 ALL
5 M/T
5 W/T/F
6 ALL
7 ALL
8 ALL
9 M/T
9 W/T/F
Half of the students Classroom
teaching & workshops in Bristol
GP placement(s) Medicine for Older People Reflective teaching and
inter professional learning in
Bristol Half of the students
Medicine for Older People GP placement(s)
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COMP2 Timetable Block 3 Week 1
Monday 27
th January
Tuesday 28
th January
Wednesday 29
th January
Thursday 30
th January
Friday 31
st January
Lecture Theatre 1 UH Bristol Education Centre 09.15 – 09.45 Introduction to COMP 2 Dr Shalini Narayan 09.45 – 12.00 Dermatology Dr Shalini Narayan
Lecture Theatre 1 UH Bristol Education Centre 09.00 – 12.15 Dermatology
Academy Academy Academy
Lunch 2.30 – 3.00
Introduction to Medicine for Older People Dr Sue Wensley Biological Sciences Building D53 3.00 – 3.30 Introduction to Ethics
Dr Sue Wensley Biological Sciences Building D53 3.30 – 5.00 Ethics Workshop Dr Sue Wensley + 3 tutors
St Michael’s Hill, Tutorial rooms 2.0, 2.1, 3.0, 3.1
1.15 – 1.50 Introduction to Primary Care Lecture Dr Jessica Buchan Medical School Building C44 2.00 – 2.50 Consultation Skills Lecture Dr Julia Sarginson & Dr Tim Davis Medical School Building C42 3.00 – 5.00 Effective Consultation Skills Workshop Dr Jessica Buchan & tutors 31-37 St Michael’s Hill, Tutorial rooms 3.3, 2.3, 3.0, 3.2, 2.0, 1.1b, 1.2, 2.2
Academy Academy Academy
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COMP2 Timetable Block 3 Week 9
Monday 24
th March
Tuesday 25
th March
Wednesday 26
th March
Thursday 27
th March
Friday 28
th March
am
Academy Academy
09.00 – 12.00 Medicine for Older People Case-based discussion Dr Sue Wensley + 3 tutors St Michael’s Hill, Tutorial rooms 2.0, 2.1, 3.0, 3.1
9.00 – 09.50 Multi-morbidity in Primary Care Professor Chris Salisbury Canynge Hall LG08A/B 10.00 – 10.50 Intimate Partner Abuse Professor Gene Feder & Dr Emma Howarth Canynge Hall LG08A/B 11.00-11.50 Risk of Cardiovascular Disease Dr Andrew Blythe Canynge Hall LG08A/B
9.00 – 9.50 Minor Illness Dr Lucy Jenkins and Professor Alastair Hay Medical School Building C44 10.00 – 10.50 Disability Lecture Dr David Memel & Dr Hannah Condry Medical School Building C44 11.00 – 1.00 Disability Tutorials Dr David Memel and tutors 31-37 St Michael’s Hill, Tutorial rooms 1.1a, 1.2, 2.0, 2.1, 2.2, 3.0
Lunch
pm
Academy Academy
1.30 Dermatology Reflective Teaching Dr Shalini Narayan Lecture Theatre 1 UH Bristol Education Centre
2.00 – 2.30 Prescribing Dr Sue Wensley + 5 tutors Lecture Theatre A1.4 St Michael’s Hill 2.30 – 5.00 St Michael’s Hill, Tutorial Rooms 2.0, 2.1, 2.2, 3.0, 3.1 & AIMS SR2A NB. Medical Students please bring BNF
2.00 – 3.00 OSCE Revision & Feedback Dr Jessica Buchan (Lecture) Medical School Building C44
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IMPORTANT DATES AND DEADLINES
Please check your e-mail and the COMP2 Blackboard site regularly for up-to-date information on the course. Also, when you are in Bristol or on a hospital attachment, please check the notice boards in the hospital, the Medical School and the Director of Student Affairs’ Office. Thank you.
Formative assessments with GP or hospital tutor These need to be completed at the end of each clinical attachment Workshops in final week of the course Attendance at the workshops and lectures in the final days of the course is compulsory. To get the most out of these workshops you are required to do a small amount of preparatory work during your clinical placements. For the Disability workshop you need to have done some background reading (in the Primary Care Study Guide).
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COMP2 COURSE DATES FOR 2013/14
BLOCK 1: 2 SEPT - 3 SEPT 2013 INTRO TEACHING 4 SEPT – 1 OCT 2013 Medicine for Older People & Derm / Primary Care & Derm (Stream 4H/4G) 2 OCT – 29 OCT 2013 Medicine for Older People & Derm / Primary Care & Derm (Stream 4G/4H) 30 OCT – 1 NOV 2013 IPL IN PRESCRIBING/REFLECTIVE TEACHING BLOCK 2: 4 NOV – 5 NOV 2013 INTRO TEACHING 6 NOV – 3 DEC 2013 Medicine for Older People & Derm / Primary Care & Derm (Stream 4F/4E) 4 DEC – 14 JAN 2014 Medicine for Older People & Derm / Primary Care & Derm (Stream 4E/4F)
(No students over Christmas break from 16 Dec – 1 Jan 2014) 15 JAN – 17 JAN 2014 IPL IN PRESCRIBING/REFLECTIVE TEACHING
EXAMS FOR STUDENTS IN BLOCKS 1 & 2
Tuesday 21
st January 2014 OSCE EXAM (FRENCHAY & CHELTENHAM)
Friday 20th
June 2014 MCQ/EMQ WRITTEN EXAM
BLOCK 3: 27 JAN – 28 JAN 2014 INTRO TEACHING 29 JAN – 25 FEB 2014 Medicine for Older People & Derm / Primary Care & Derm (Stream 4B/4A) 26 FEB – 25 MAR 2014 Medicine for Older People & Derm / Primary Care & Derm (Stream 4A/4B) 26 MAR – 28 MAR 2014 IPL IN PRESCRIBING/REFLECTIVE TEACHING BLOCK 4: 31 MAR – 1 APRIL 2014 INTRO TEACHING 2 APRIL – 6 MAY 2014 Medicine for Older People & Derm / Primary Care & Derm (Stream 4D/4C)
(No students over Easter break from 18 April – 27 April) 7 MAY – 3 JUNE 2014 Medicine for Older People & Derm / Primary Care & Derm (Stream 4C/4D) 4 JUNE – 6 JUNE 2014 IPL IN PRESCRIBING/REFLECTIVE TEACHING
EXAMS FOR STUDENTS IN BLOCKS 3 & 4
Tuesday 10
th June 2014 OSCE EXAM (FRENCHAY & CHELTENHAM)
Friday 20th
June 2014 MCQ/EMQ WRITTEN EXAM
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STAFF INFORMATION
Details of Academy Medical Deans and Administrators along with Centre for Medical Education staff can be found at www.medici.bris.ac.uk/students. For support outside your Unit you can contact your Personal Tutor or the Director of Student Affairs (0117 331 1844). Full details of student support services are available at: The medical teachers in COMP2 include general practitioners, consultants, staff physicians and trainee medical staff. COMP2 encompasses inter-professional work and you will receive teaching from nurses, therapists, dieticians, pharmacists and social workers. Students need to play a part in the organisation of student firms. Each group attached to an academy for COMP2 should appoint a student as firm leader whose responsibility it is to liaise with the lead clinicians, unit tutor, teaching administrator and clinical sub-dean.
Element Organisers
Element Administrators
Dermatology Dr Shalini Narayan Bristol Dermatology Centre, BRI Tel: 0117 3423416 [email protected]
Mrs Kate Prys-Roberts Level 7, Bristol Royal Infirmary Tel : 0117 3422103 [email protected]
Primary Care Dr Jessica Buchan School of Social and Community Medicine Canynge Hall Whatley Road, Bristol, BS8 2PS [email protected]
Mrs Mel Butler School of Social and Community Medicine Canynge Hall (Room 1.01) Whatley Road, Bristol, BS8 2PS Tel : 0117 92 87256 [email protected]
Medicine for Older People Dr Sue Wensley (also Unit Lead) Medicine for Older People, Frenchay Hospital Tel: (0117) 3406563 (NHS Secretary) Tel: (0117) 3432362 (NBT Academy) [email protected]
Mrs Sharon Byrne 69 St Michael’s Hill Tel : 0117 3311689 [email protected]
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Academy tutors for Medicine for Older People
Bath Dr Robin Fackrell
Dr Kate Peacock
Cheltenham/Gloucester Dr Tom Millard
Dr Sangeeta Kulkarni
North Bristol (Frenchay/Southmead)
Dr Sue Wensley [email protected]
South Bristol
(BRI/Bristol General)
Dr Julie Dovey [email protected]
Somerset:
Taunton
Yeovil
Dr Simon Cooper
Dr Khalid Rashed
Swindon Dr Sarah Woods
Dr Debbie Finch
Dr Anil Ipe
Academy tutors for Dermatology
Bath Dr Sarah Woodrow [email protected]
Cheltenham/Gloucester Dr Tom Millard [email protected]
Bristol Dr Shalini Narayan [email protected]
Somerset:
Taunton
Dr Damian Pryce
Swindon Dr Sam Gibbs [email protected]
GP Leads for Primary Care
Bath Dr Melanie Blackman [email protected]
Cheltenham/Gloucester To be confirmed
South Bristol Dr Sarah Jahfar [email protected]
North Bristol Dr Barbara Laue [email protected]
Somerset (Taunton) Dr Charles Macadam [email protected]
Somerset (Yeovil) Dr Andy Eaton [email protected]
Swindon Dr Lindsay O’Kelly [email protected]
External Examiners
Dr Stuart Cohen Nottingham University Hospitals NHS Trust
Dr Sandra Nicholson Queen Mary, University of London
Please do not contact the external examiners
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TEACHING INFORMATION
THE CLINICAL ATTACHMENTS
The time that you should spend on the various components of the course is roughly as follows: Primary Health Care 40% Dermatology 20% Medicine for Older People 40% In order to continue clerking skills developed in year 3 a clerking assessment portfolio is now part of the COMP2 assessment
PRIMARY HEALTH CARE
33 half-day sessions of the course are devoted to learning about Primary Health Care. During this time you will be attached to one or two GP surgeries and will attend a variety of lectures/workshops. In total you will have: 3 sessions of lectures/workshops held in Bristol 30 sessions of clinical teaching during your GP attachment(s) Your GP attachments give you a unique opportunity for learning. You will be taught on a one-to-one basis and will gain experience in conducting consultations by yourself. You may be taught by many different doctors within a single practice but one doctor will be identified as your key teacher. Most of you will have a 4-week GP placement but some of you will have two 2-week placements. During the four weeks you will have 30 sessions (half days) of teaching. This leaves 10 sessions which may be timetabled for dermatology teaching and private study time to complete the on line primary care tutorials on blackboard. Some of the attachments (mainly those in rural areas, some distance from the academy base) will require you to live with the GP. Residential placements will usually only be for 2 weeks. These attachments have proved very popular with students in the past and if you have specifically requested one, every effort will have been made by the Primary Care teaching administrator, to meet your request. Hopefully those of you attached to the Bath, Gloucestershire, Somerset and Swindon academies will have all of your GP attachment(s) in the vicinity of a single academy. If your GP does not provide accommodation then you will be given accommodation by the academy. Those of you attached to a Bristol academy may have a residential GP attachment in Devon, Somerset or South Gloucestershire but will be in Bristol for the rest of the time. As soon as you know which practices you have been allocated please contact your GP teachers by phone or e-mail to confirm that you will be attending. Your GP teachers will have to prepare a timetable for you in advance of you arriving and this will involve them re-arranging their surgeries to free up time for teaching.
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First 2 weeks of GP attachment At the start of your GP attachment you should talk to your GP teacher about what you would like to get out of the attachment. Think about what your strengths and weaknesses are and what you need to concentrate on to maximise your learning. Use the 16 ‘core problems’ to identify areas of weakness. During the first week of your first GP attachment you will sit in on surgeries with your GP teacher. Your GP teacher will invite you to comment on the consultations that you witness and over the course of the week will encourage you to start participating in some of the consultations. You should reflect on what you see and hear and should start to complete the first table in the logbook entitled “Table A: Case Log of consultations that you have observed”. During the second week of your first GP attachment you will start to do some consultations by yourself, with your GP teacher watching you. At the back of your study guide is a reflective log for you to should consultations that you observe and that you do yourself, with your GP watching. Please record your teacher’s comments and your own thoughts on these consultations; then try to establish what you have learned from them. You should also take your CAPS (consultation and procedural skills logbook) with you to your attachment so that your GP can sign you off for at least one consultation they have observed you conducting. As well as sitting in with your key GP teacher you will probably spend time with other GPs in the practice too. GPs have different consultation styles and sometimes attract different patient profiles so spending time with different GPs may broaden your experience. You may also have the opportunity to spend time with other members of the Primary Health Care team such as the treatment room nurses and district nurses. Throughout the fortnight you should have lots of opportunities to be observed consulting with and examining patients. The most important exam for COMP2 is an objective structured clinical examination in which you will have to conduct consultations with patients. So, during your GP attachments you need to ensure that you master the basic steps in conducting a consultation within general practice and that you are proficient in examining patients. During the attachment your teacher will offer you at least one tutorial. It is up to you and your teacher what you concentrate on during these tutorials. You may want to explore issues arising out of a consultation that you have observed or participated in. Alternatively, you may want to focus on one of the clinical problems that constitute the core syllabus for primary care. There are 16 core problems in the primary care syllabus; listed the primary care study guide and also listed in the chapter on the COMP2 syllabus in this handbook. If you are moving to a different practice for your second 2 weeks, at the end of your first attachment you should spend some time completing the handover form at the back of your study guide. This form should summarise your achievements during the attachment and identify your goals for the next attachment.
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Second 2 weeks of GP attachment If you are in a new practice for your second 2 weeks you should show the handover form to your new GP teacher on your first day. Your new teacher will invite you to sit in on consultations but will probably encourage you to start doing your own consultations early on in the fortnight. Some teachers may set up special surgeries for you to run (under their supervision) during your second 2 weeks. How much you do will depend upon your ability, your confidence, logistics (such as the availability of spare room) and the slot in which you are studying COMP2. If you are studying COMP2 at the start of year 4 you will not have learned about obstetrics, gynaecology or paediatrics yet. However if you are studying it at the end of year 4 then you should know about these topics already and you should find general practice easier. As in your first GP attachment you should be observed doing a minimum of 5 consultations and can record your reflections on these consultations in the back of your primary care study guide During your second 2 weeks attachment you also have a further tutorial.
DERMATOLOGY
15 sessions of the course are devoted to Dermatology 2 are Bristol-based lectures during the first week 1 session of reflective learning in week 9 12 are out-patient clinics/tutorials/self-directed learning within the academies or at BRI for Bristol Academies. The 12 out-patient clinics/tutorials/self-directed learning sessions take place throughout the Medicine for Older People and Bristol GP placements. The precise timing will vary according to the individual student and academy
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MEDICINE FOR OLDER PEOPLE
38 sessions of the course are devoted to learning about Medicine for Older People 3 sessions of lectures & workshops in weeks 1 & 9 of the course 35 sessions (or ‘half-days’) of Planned Clinical Work (outpatient clinics, ward rounds, community visits, ward work, ring fenced tutorial time) spread out over 4 weeks. The remaining 5 sessions of these 4 weeks are reserved for dermatology teaching. At the clinical academy, one of the lead consultants/associate specialist/teaching administrators will meet with you on the first morning, give you your timetable and show you round the relevant clinical areas including the postgraduate centre and library. You will obtain the contact details of the single administrative point for this attachment through which alterations can be made regarding the timetable or problems can be sorted regarding accommodation. If you are sick, you must make contact with this administrator and your tutor. Each group of students should have a bleep/mobile number so that clinical and administrative staff can keep in touch. Students within an academy must have a similar clinical experience, so if the timetable does not specify which students go to different sessions, then this should be allocated on the first day to reflect approximately the following weekly sessions:
1-2 sessions in Medicine for Older People or specialist outpatients/day hospital
1-2 session involving a Medicine for Elderly ward round and attending board rounds
1 session per four weeks for one general MDM and one stroke MDM (spend ½ -1 hour in these)
1-2 session for the weekly tutorial in Medicine for Older People
2-3 sessions in Medicine for Elderly for clerking/following up patients in the ward/day hospital/patients home/ or spending a session with hospital-at-home/visiting intermediate care activities-
1 session Bedside teaching
1-2 sessions in Dermatology out-patients/tutorials
Tutorials in Medicine for Older People The two tutorials per week will take place either in a single ring-fended session, or as two separate sessions during that week. A consultant/associate specialist/registrar/nurse consultant will lead/facilitate these. These tutorials require students to take turns finding a patient with the topic and spending the first 5-10 minutes informally describing the key points about this patient, from medical and non-medical perspectives. PowerPoint presentations for tutorials are to be found on Blackboard This student can also lead the PowerPoint presentation. It is important to speak to nurses, therapists and social workers about the patient. Once the tutorial starts, carry on relating the patient discussed to points raised in the tutorial.
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Some clinicians may not use the interactive tutorial, but use their own, the group can still look at the Blackboard tutorial after. The lectures from the previous years are also available on blackboard. Occasionally, several staff can be away within the same week, but tutorials must never be cancelled, they need to be re-arranged. If it is not possible to undertake the required tutorials within a week then they must be doubled up the following week. We strongly advise students to get in touch with Sharon Byrne if there are any problems delivering tutorials. There are four other tutorials linked to the core problems, which may be delivered by other professionals but are also designed for self directed learning. Please have a look on blackboard. Aphasia and dysphagia Incontinence Hypothermia Pressure sores Caring and stress in carers Nottingham University has created a number of interactive tutorials which cover the Core Topics. The links to these are on blackboard. These are very useful so please have a look at these. There are ample other teaching materials to be found on the web. As students it‘s often helpful to cover the core topics as a group. Working as a group, you are more likely to understand what you know and don’t need to know and help yourselves together. In any firm there is spare time between ward rounds, or outpatient clinics, the lecture notes study guide is there for you to read during these times.
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AIMS & OBJECTIVES
PRIMARY CARE By the end of the unit you should be able to:
Describe the role of the GP, other members of the primary health care team and the
other systems that provide open access health care in the UK
Conduct a complete consultation on any of the 16 core clinical problems listed (page 4).
Including: o Consulting effectively with a patient with a disability o Identifying patients at risk of intimate partner violence and having strategies to
help them o Understanding how the delivery of bad news impacts on patients and carers
Describe the risks and benefits of commonly prescribed medication used in the treatment of these 16 core problems and understand the rationale behind making treatment decisions.
Help patient reduce their risk of developing chronic disease and use data interpretation e.g. blood pressure measurement and cardiovascular risk to inform management.
Understand the impact of multi-morbidity on the individual, and on health care services
Describe methods by which the impact of disability on patients can be minimised
DERMATOLOGY By the end of this unit you should be able to:
Take a dermatological history and explore a patient’s concerns and expectations
Examine the skin systemically (including palpation)
Describe and record findings using accepted dermatological terms
Recognise and appreciate the incidence and appropriate management of common skin disorders and skin cancers and be familiar with principles of topical therapy
Interact sensitively with people with skin diseases
MEDICINE FOR OLDER PEOPLE By the end of this unit you should be able to:
Describe common health problems in old age and their drug and non-drug management
In an older patient with complex physical and social problems who is hospitalised or residing in the community:
o Know the principals of Comprehensive Geriatric Assessment (CGA) Carry out a clinical assessment, construct working diagnoses Define appropriate investigations and management plans Name team composition, roles, processes and services meeting the
specific patient and family needs
Perform and interpret the functional assessments commonly used in older people
Describe the processes of assessment and rehabilitation
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List the services available in the community to support older people (with physical and/or cognitive disability) and carers in their homes and explain the range of residential options distinguishing between them in terms of the level of care provided and the broad criteria used in relation to patient needs.
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LEARNING OUTCOMES Core problems in Primary Care
Problem Presentation Learning objectives Asthma, angina My chest feels tight Describe how to diagnose asthma & angina, when to refer & how
to manage these conditions including commonly used medications.
Chronic obstructive pulmonary disease (COPD), anaemia, heart failure & smoking
I get out of breath easily Describe how to diagnose & manage COPD and heart failure including the main treatment options. Describe how to investigate anaemia. Demonstrate ability to help someone stop smoking and have an understanding of the main medications used including nicotine replacement.
Common cancers: lung, bowel, prostate & breast
I’m losing weight; I’m still coughing; I’ve got a pain here (left iliac fossa); I have to go to the toilet all the time; I’ve found a lump in my breast
Describe how these 4 common cancers might present and know how to reach a definite diagnosis. Describe how to manage a patient who is terminally ill as the result of any of these cancers.
Contraception I’d like to go on the pill Be familiar with at least one combined oral contraceptive pill. Demonstrate how to assess a patient before starting her on the pill and how to follow her up. Discuss methods of post-coital contraception. Discuss contraception options.
Depression I feel useless Be alert to possibility of depression and use skilful questioning to confirm diagnosis. Be familiar with at least one antidepressant drug.
Diabetes, anaemia, hypothyroidism, insomnia, depression, early pregnancy, chronic fatigue syndrome
I feel tired all the time List differential diagnosis of tiredness. Describe presentation, investigation & management of each of these conditions.
Domestic violence I have tummy ache I can’t sleep
Identify patients who may be at risk of intimate partner violence and have strategies to help them
Gastroenteritis I’ve got diarrhoea Describe management of diarrhoea in adults
Gastro-oesophageal reflux & alcohol dependence
I’ve got heartburn Describe investigation & management of heartburn understand the role of medication in the aetiology of heartburn, and in managing heartburn. Demonstrate ability to recognize alcohol dependence & offer help with stopping drinking.
Hypertension and cardiovascular risk
The nurse said my blood pressure was high
Demonstrate how to diagnose and manage hypertension including choosing treatment options. Demonstrate how to estimate the risk of someone developing cardiovascular disease over the next 10 years. Be familiar with the indications for prescribing statins including the risks, benefits and monitoring required. Describe the role of a GP in managing patients following a myocardial infarction. Discuss the use of sildenafil in a patient presenting with erectile dysfunction.
Migraine & tension headache
I’ve had a headache for the last 2 days
Demonstrate how to assess a patient with a headache. Discuss treatment & prophylaxis for migraine.
Non specific low back pain
My back hurts Demonstrate management of back pain & discuss when investigation is warranted.
Otitis media & externa My ear hurts List differential diagnosis of earache & management options for otitis media & externa including medications used.
Substance misuse My wife says I am drinking too much alcohol. Can you prescribe me some methadone?
Make an initial assessment of someone with an alcohol or drug problem. Be aware of the associated medical and social problems. Gain understanding of services for addicts within primary care.
Urinary tract infection, chlamydia & common STDs
It stings when I go to the toilet
Demonstrate how to manage simple UTIs including commonly prescribed antibiotics. Be alert to possibility of prostatic hypertrophy/ cancer in men. Be alert to possibility of STDs causing dysuria. Feel confident in taking a sexual history.
Viral sore throat, glandular fever, tonsillitis, upper respiratory tract infection and influenza
I’ve got a sore throat Discuss management options for each of these conditions including commonly prescribed antibiotics. Communicate the potential benefits & disadvantages of antibiotics to the patient. Be able to counsel a patient on the use of simple over the counter analgesics e.g. paracetamol and non steroid anti inflammatories. Understand the flu vaccination and when it should be issued.
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Core problems in Dermatology
Problem Presentation Details Rash I have a rash Establish time and site of onset, progression and symptoms, both physical and
psychological. Ask about relevant personal and family history (e.g. atopy, psoriasis) and treatments used.
Eczema I’ve got eczema/dermatitis
Recognise pattern and evolution of different types of eczema – endogenous (eg. atopic, seborrhoeic, discoid, varicose) and exogenous (contact dermatitis). Know principles of management.
Psoriasis I’ve got psoriasis Recognise different forms of psoriasis and natural history. Describe different topical and systemic treatments.
Itch I am itchy Identify onset and progression. Assess severity of itch (? sleep loss), any associated rash (weals, urticaria) and general health.
Blisters I have blisters Establish onset and progression. Differentiate fluid-filled lesions from oedematous weals. Assess associated symptoms, e.g. itch, pain. Remember superficial blisters may become easily ulcerated.
Skin Tumours (benign and malignant)
I‘ve got a lump Establish site and nature of changing or new lesion and associated symptoms. Ask about previous skin tumours. If relevant, assess previous sun exposure, relevant family history and skin type. Be able to recognise photodamage, typical BCC, SCC and malignant melanoma.
Acne I’ve got spots Age of onset and progression. Assess associated psychological morbidity. Identify previous treatments, and assess factors that may influence potential treatments.
Leg ulcer I’ve got leg ulcers Know causes of leg ulcers, principles of assessment and management
Hair changes I’ve got too much / too little hair
Establish onset, progress and degree of psychological morbidity. Know causes of scarring and non-scarring alopecia, hirsutism.
Dermatological treatments
I don’t know which cream / ointment to use
Know how and when to use a variety of emollients and soap substitutes. Describe range of potencies of topical steroids and appropriate use. Vit D analogues, coal tar, dithranol.
Skin disease prevention
How do I protect my skin?
Know how to advise about sun protection. Know how to advise for inflammatory skin problems, especially eczemas.
Examination General physical examination is often indicated Rash Extent, discrete/diffuse, symmetrical?
Assess colour, epidermal change and degree of inflammation or induration. Evaluate nail, scalp, oral or mucous membrane changes where relevant.
Lump Superficial or deep. Size, shape, colour, location, ulceration.
Blisters Intact or eroded. Nature (soft, firm). Fluid/blood/pus filled. Assess background rash or mucosal involvement.
Acne Assess nature and extent of lesions and degree of scarring.
Leg ulcer
Site, size. Appearance of ulcer and surrounding skin. Assess background venous changes and palpate peripheral pulses.
Hair Assess extent and pattern of hair change. Scarring or non-scarring alopecia. Assess relevant skin changes elsewhere.
Diagnostic tests
Skin swabs Indications for both bacterial and viral swabs, and interpretation of results.
Skin, nail + hair mycology
Indications for skin scrapings, nail clippings and hair mycology. Knowledge of how these are performed and interpretation of results.
Patch testing Indications for patch testing and some knowledge of result interpretation.
Doppler studies/ ABPI
Indications and interpretation.
Skin biopsy Indications and practical knowledge of how this is performed and when additional tests should be requested (e.g. immunofluorescent studies).
Blood investigations Awareness of relationship of skin problems with underlying disease and indications for appropriate blood investigations.
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Check list – all students should be familiar with the following skin diseases (dermatoses), with detailed knowledge of conditions in capitals:
Infections CELLULITIS Herpes Simplex and Zoster IMPETIGO and other staph infections Necrotizing fasciitis SCABIES Tinea and candidiasis Viral Warts
Inflammatory skin disorders ACNE and rosacea Bullous pemphigoid and Pemphigus ECZEMA of various types Erythroderma PSORIASIS URTICARIA, angiodema, anaphylaxis
Cutaneous signs of systemic diseases
Skin Tumours BASAL CELL CARCINOMA BENIGN NAEVI Bowen’s Disease (in situ squamous cell carcinoma) Malignant melanoma SEBORRHOEIC KERATOSIS SOLAR (ACTINIC) KERATOSIS SQUAMOUS CELL CARCINOMA
Pigmented disorders Melasma (chloasma) Vitiligo
Alopecia of various types Drug eruptions including Erythema multiforme Stevens Johnson syndrome Toxic epidermal necrolysis
Dermatological history – a guide to possible questions
1. Duration of rash? 2. Where did the rash start? 3. Did it spread? Slowly or rapidly? 4. Do the spots come in crops? 5. Has the rash ever blistered? Were the blisters
filled with clear fluid? 6. Does it itch? 7. How does sunlight affect the rash? 8. What makes the rash better?
9. What makes the rash worse? 10. What tablets or medicines have you taken? 11. What ointment/cream have you used on the rash? How
long? Did it help? 12. Do you have any contacts with a similar rash? 13. Any history of previous skin disease? 14. Any history of childhood eczema, asthma, urticaria or hay
fever? 15. Any family history of skin disease? 16. Anything triggered the rash? 17. How does it affect you?
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Core Problems in Medicine for Older People
Essential Core Medical Illnesses
Problem Presentation Details e.g. Relevance to Foundation years and frequency seen in Hospital
Dementia “My mum keeps forgetting things and its getting worse”
See lectures/handbook/tutorials/case scenarios Know prevalence+age relationship. Explore pre-disposing factors, duration of onset, patterns of cortical impairment, behaviour. Know different causes and pathologies, ethical aspects, treatment including multiprofessional team, family impact and support available
Medical take-common Surgical take common GP practice common 25% of all inpatients
Delirium (acute confusional state)
“My husbands been confused the last few days and he’s had a temperature” “The doctor started my dad on some new tablets for his Parkinson’s disease and he’s become confused”
Know that Cognitive testing should be carried out on all older people admitted to hospital Understand that identification and treatment of the underlying cause is crux of management Understand the wide variety of causes that predispose to delirium Know that an independent history from a carer, GP or relative is often required
Medical take common-40% of medical take Surgical take common GP practice common on call
Dizziness and syncope
“I keep getting dizzy and finding myself on the floor”
Know definitions, prevalences and underlying causes. Describe important points in history taking and examination, relevant investigations and management plans. Define evidence base for Rx from RCTs. Define factors in the fracture-prevention triangle and role of multi-professional team in management.
Medical take common Orthopaedic Take- common Fractured hips/pelvis/wrists/humerus
Falls “My father has had 3 falls in the past month”
Know causes of falls Be able to take an accurate history, accurate examination especially musculoskeletal and neurological, gait analysis
Medical take-common Orthopaedic Take- common Fractured hips/pelvis/wrists/humerus
Fracture neck of femur and osteoporosis
“Now, they tell me, I’ve broken my hip and need an operation”
Know precipitating causes of falls/osteoporosis Complications of surgery Treatment options Rehabilitation aspects National guidance
Medical out patients- osteoporosis very common Orthopaedic take- fractured NOF common GP practice Osteoporosis-common
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Problem Presentation Details e.g. Relevance to Foundation years and frequency seen
Immobility
“I just sit in the chair, it’s too much effort to do anything”
Detect diagnostic indicators in history taking and examination. List common relevant investigations and treatment approaches including role of multi-professional team. Be able to assess cognitive and affective state
Medical take-common GP practice on call-common
Stroke and TIA
“My right hand went dead and I could not get my words out”
Know definitions, prevalence. Identify cardiovascular risk factors from clerking. Recognise TACI, PACI, POCI, Lacunar from clerking. Describe specific investigations and management plan. Define evidence base for Rx from RCTs. Recognise and discriminate large intracerebral haemorrhages and infarcts on CT scan. (Rehab-see below)
Medical take-common Surgical patients-maybe seen post op
Drug prescribing problems
“These are all the tablets I am on”
Following clerking, identify common causes for drug interactions and methods by which adherence can be enhanced
Medical take-common Surgical take –common Orthopaedic take common
Frailty “My mum has been loosing weight over the last few years and has no resistance to infections”
Know the frailty phenotype Recognise poor prognostic indicators
Medical take-common Surgical take-common Orthopaedic take-common Primary care-large numbers of patients esp. residential and nursing homes
End of life issues in frailty and extensive comorbid disease
Mr Smith is deteriorating despite all active treatment
Be aware of NICE quality standards Introduction to DNACPR Understand concepts of futility Introduction to Integrated Care for the dying.
Medical take and wards-common Will cover again in year 5 palliative medicine
Legal and ethical aspects in Older People
My patient is confused and I don’t know how to discuss this treatment with him
Know about the legal concepts of capacity to make a decision, best interests decision making, IMCA, lasting power of attorney
Medical and Surgical patients -common
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Important problems
Carer strain “I can’t carry on any longer, he will have to go into a home”
Describe predisposing factors and community approaches used to support carers
Medical and surgical take-common
Hypothermia
“The ambulance men found me, ‘stone cold’ they said”
Give definition. Know importance of low-reading thermometers in diagnosis. Define physiological, environmental and psychosocial factors in causation. Describe acute treatment and 2
ary prevention
Medical take-occasional Acutely Managed usually by A/E, Complications seen on medical take
Parkinson’s Disease
“The shaking in my hand is getting worse and no-one can read my writing now”
Identify diagnostic clinical features from history and examination. Give differential diagnosis. Explain pathophysiology and drug and non-drug approaches to treatment including multi-professional team approaches. Define natural history and impact on patient+carers.
Outpatients predominantly Medical take
Pressure Sores
“There is some redness and broken skin on his bottom”
Describe predisposing factors, 1ary
prevention in hospital + community and acute treatment. Describe pressure sore risk assessments Recognise that all pressure sores need photographing and reporting-an AIMS form (or similar) needs completing(Accident and Incident Management system)
Hospitalised patients-can occur on admission e.g. long lie, can develop in hospital when rapid change in clinical status Primary care-seen in nursing homes, high dependency states
Urinary and faecal Incontinence
“I have lost all control of my waterworks, I cannot go out, it is so embarrassing”
Describe causes, relevant investigations and treatment approaches including specialist nurses (see below)
Medical/Surgical take-common Primary care-common, especially in residential and nursing homes
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Assessment Tools:
Folstein Mini-Mental test-MMSE Abbreviated mental test score AMT Addenbrooks Cognitive Examination ACE-R MOCA (Montreal Cognitive assessment)
Standard assessment scores used to assess cognition See above
BASDEC or Geriatric Depression Scale (GDS)
Objective Validated Standard tests of affect screening for depression Basdec-score out of 21- GDS score out of 15 Hamilton score out of 30 Higher scores indicate more depression Please use and become familiar with applying-note not valid if a patient is demented. Use the Cornell score (observational depression score)
Barthel Index Functional scale
Identify clinical situations where functional assessments are utilised, know where use is inappropriate Originally developed for stroke rehab-two scales Out of 20 and 100
Berg balance score Used by physios to assess how stable someone is, often mentioned in MDMs Score out of 56, lower score, worse balance!
3. Processes of care, specialist staff and national standards
Specialist nurses (stroke, continence, ortho-geriatric, movement disorders)
Identify roles in Medicine for older people and in conditions listed above, identify appropriate team composition for assessment/rehabilitation and ingredients for effective ‘team-work’ in Medicine for older people
Therapists (physio-, occupational and SALT)
Pharmacist
Dietician
Social worker
Comprehensive Geriatric Assessment
Describe basis for use and main ingredients See week 1 lecture
Rehabilitation Define process in relation to post-fracture neck of femur and stroke. Define evidence-base from RCTs
Intermediate care Give an example of community-based rehabilitation and purpose e.g. Hospital-at-home
Social service and health support in the community for older people at home
List services available to support older people and carers with physical disability +/- cognitive impairment
Very sheltered accommodation Residential home Nursing Home
Explain range of options, distinguish them in terms of level of care/trained nursing staff/ability to manage needs of patient
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PROFESSIONAL BEHAVIOUR You should adhere to the professional code of practice at all times which can be found at: www.medici.bris.ac.uk/student/copaccept As stated in the Year 4 handbook, all students must also satisfy their teachers in terms of their Professional Attitudes and Behaviour. If a satisfactory standard is not achieved, this may result in failure of the unit, regardless of performance in the examinations This includes: - treating all patients with respect (including respecting confidentiality) - treating all staff and colleagues with respect (including not disrupting their teaching) - attending all teaching on time and adhering to the clinical dress code - being honest and handing in all required paperwork/assessments to deadlines - taking Medicine for your health and seeking help if your health may impact on patient care In preparing students to qualify as doctors, the University has the responsibility not only to ensure that your clinical skills and knowledge are adequate but also that you display appropriate behaviour towards patients, staff and society in general. Skills and factual knowledge can be objectively assessed in formal exams that take place at the end of most clinical attachments. To assess students’ attitudes the University relies upon the clinical teachers who closely supervise your work. Following consultation with their colleagues, teachers will assess you as satisfactory, or not in the following categories: appearance, attendance and punctuality, attitude and behaviour. Your teachers should point out anything they perceive as unsatisfactory so that you have an opportunity to address the issue. Teachers will be asked to provide verbal positive feedback on your attitude/behaviour. However, if a problem remains, then it will be reported to the Director of Student Affairs via a Student Concern Form and you will be asked to discuss this issue with him. The Director of Student Affairs will seek a resolution of any problems highlighted.
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TEACHING INFORMATION & EXPECTED STUDENT INPUT
PATIENTS AND CARERS You are reminded of the contents of the Code of Conduct agreement relating to access to patients and clinical work which you signed at the beginning of the clinical course. You must adhere to this at all times. To refresh your memory, the major points are reiterated in the document entitled “Rules, policies & procedures” produced by the Faculty of Medicine & Dentistry. Patients and, where appropriate, carers provide the most important resource for your learning. In Primary Care you will learn most from the time that you spend observing and conducting consultations. Use the logbook at the back of your study guide. Discuss the patients who you have seen with your GP teacher. Think about what problems each patient brought to the GP surgery and analyse how you/the GP made a diagnosis. If you see a patient with a particular problem read up about it later that day. You will also learn from accompanying the GP on home visits and by spending some time with other members of the primary health care team, the practice nurses and district nurses in particular. For Dermatology, you will learn predominantly in the out-patient setting. A variety of tutorial and in-patient experiences may also be available. If, during the course of your attachment, there are gaps in your clinical experience, please mention this to your dermatology teacher. For Medicine for Older People, you will meet patients in hospital wards and clinics, and for some of you, visit patients in their homes. You must ensure that you obtain experience in clerking patients, taking collaborative histories and this should include the identification of the main differential diagnoses, specific investigations that match the differential diagnoses and finally a management plan. This will form your clerking portfolio and will account for 10% of your overall assessment. Learning about continuity of care is important. For in-patients, you should follow patients up during your attachment. Patients may be admitted under one team and transferred to another team, which may be surgical or medical. Seek permission from the team responsible for the patient and continue to follow the patient up during the attachment. Speak with the patient and staff and review the medical and nursing records and the drug chart. Where a patient has difficulty communicating, is confused or too ill to speak with you, prior to having discussions with next-of-kin, ensure nursing staff indicate that this is appropriate.
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ON-TAKE & OUT-OF HOURS COMMITMENTS During each GP attachment your GP teacher is likely to be the “duty doctor” for the practice at least once. On these days your GP is likely to see more urgent problems and will probably admit at least one patient to hospital. Ask your GP if you can accompany them for some of the time on one of these days and offer to stay until the end of evening surgery. Your GP may be very busy on these days and may not have as much time for teaching but you will see another side to general practice and will learn a lot. Not all GPs work at nights or on weekends now but at most teaching practices there are GPs who do out-of hours work. The nature and pace of work out-of-hours can be very different. Ask your GP teacher if it’s possible for you to accompany them or someone else on an out-of-hours shift. About half of the GP teachers say that they can offer this and a quarter of students get some exposure of out-of-hours work during their GP attachments. The majority of those students who experience out-of-hours work in general practice find it a useful experience. It isn’t compulsory though. In Medicine for Older People, the patients admitted as an emergency offer excellent learning opportunities. As a student group, it is important to take turns being ‘on-take’ and the richest learning will come from those patients aged 75 years and over. There is no need to stay beyond 19.00 hrs. Each of you should be on-take clerking older people for 2 days during the clinical attachment. It is sensible that when you are on-take, you work with another student so that you can share your findings and also have another student with you when you leave the hospital buildings. Make yourself known to the medical registrar and ask to be allocated to elderly patients. Try and clerk the patients before they have been seen by the medical team (if this is appropriate). Keep these clerkings for your folders to be used for the tutorials. Follow up these patients through the hospital regardless of whether they go to medical wards or not. Keep regular entries as to their management and progress.
SELF-DIRECTED LEARNING As well as seeing patients you should learn by
Reading the study guides in Primary Care, Medicine for Older People and Dermatology. We give you paper copies of these and they are also on the COMP2 Blackboard website.
Using the on-line resources on the COMP2 Blackboard website
Reading the essential recommended textbooks
Reading journals, in particular the British Medical Journal.
BLACKBOARD COMP2 has a growing collection of learning resources on Blackboard. Go to www.ole.bris.ac.uk. Once there you should find that you have been registered as a student; if not, then please contact Sharon Byrne ([email protected]). As well as finding copies of the study guide on Blackboard, you will find tutorials and interactive quizzes. You will find these particularly useful when you start your revision.
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USEFUL WEBSITES The tutorials on Blackboard have hyperlinks to other useful websites. The NHS Library has an excellent collection of up-to-date detailed notes on the management of common problems in Primary Care. These are referred to as Clinical Knowledge Summaries and can be accessed free at www.cks.library.nhs.uk . They used to be known as Prodigy and are designed primarily for GPs to use during their consultations. However they are an excellent resource for medical students too and tell you what and how to prescribe, something which textbooks often avoid. The NHS Direct website www.nhsdirect.nhs.uk is a comprehensive website for patients and is also kept up to date. It is worthwhile looking at some of the patient information leaflets that it contains. These leaflets are also referred to in the Clinical Knowledge Summaries. Through the University Library porthole you should have access to all the major journals including the BMJ. If you are a member of the BMA you should have a register with BMJ Learning www.bmjlearning.com. This is an outstanding on-line learning resource aimed at all doctors. Many of the modules for GP and foundation doctors are of particular relevance to COMP2. For learning about common problems in general practice previous students have recommended www.gpnotebook.com. Many GPs refer to this website regularly in the course of their normal surgeries. Many of the tutorials on Blackboard have hyperlinks to other useful websites. Useful dermatological websites include the British Association of Dermatologists www.bad.org.uk and the New Zealand dermatology website http://dermnetnz.org/ Useful websites for Medicine for Older people-look at www.bgs.org.uk medical student section for a number of e-learning modules on delirium/dementia and falls
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RECOMMENDED READING There should be copies of the Primary Care books in each teaching practice and in the Canynge Hall Library. For Dermatology and Medicine for Older People, the books should be in the Postgraduate Centre library, the Bristol Dermatology Centre Library, as well as the main University library.
Primary Care Essential reading Bristol University Primary Care Study Guide 2012-13 (we will provide you with a copy)
Reference books Edited by Stephenson, A. A Textbook Of General Practice, 3rd Ed. London: Arnold; 2011 Simon, C, Everitt, H, Kendrick, T. Oxford Handbook of General Practice. 3
rd Ed. Oxford: Oxford University Press;
2009. Hopcroft, K and Forte, V. Symptom Sorter. 4th Ed (revised). Oxford: Radcliffe; 2010. Storr, E, Nicholls, G, Leigh, M & McMain S. General Practice: Clinical Cases Uncovered. Blackwell 2008. If you want to explore a topic in greater detail have a look at: Khot, A and Polmear. Practical General Practice: Guidelines for Effective Clinical Management, 6
th Ed
(revised). Churchill Livingstone; 2010.
Dermatology Small textbooks Gawkrodger, DJ. Dermatology. Churchill Livingstone; 4th Edition 2007. Dermatology: A handbook fir medical students and junior doctors. Available from British Association of Dermatologists website Hunter, JAA, Savin, JA, Dahl, MV. Clinical Dermatology, 3rd Ed. Blackwell Science; 2002. Reference books Burns, Breathnach, Cox, Griffiths. Textbook of Dermatology, 7th Ed. London: Blackwell Science, 2004 Bolognia, Jorizzo, Rapini. Dermatology. Moslby; 2003.
Medicine for Older People Essential reading
Bristol University Medicine for Older People Study Guide 2012-13 (we will provide you with a copy). Reference books
Oxford Textbook of Geriatric Medicine, 2nd Ed. J Grimley Evans, T Franklin Williams, Lynn Beattie, Michel Jean-Pierre & G K Wilcock: Oxford University Press
Brocklehurst’s Textbook of Geriatric Medicine and Gerontology, 7th Ed. Raymond C Tallis & Howard M Fillit: Churchill Livingstone Recommended Reading
Oxford Handbook of Geriatric Medicine (Oxford Handbooks Series) 2nd Ed. Lesley K Bowker, James D Price & Sarah C Smith: Oxford University Press
Elderly Care Medicine (Lecture Notes Series). Claire Nicholl, Jane Wilson & Stephen Webster: Wiley-Blackwell
Essential Facts in Geriatric Medicine. Catherine Bracewell, Rosaire Gray & Gurcharan S. Rai: Radcliffe Publishing Ltd
Medical Ethics and the Elderly, 3rd Ed. Gurcharan S. Rai
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ASSESSMENT INFORMATION
All assessment information is being kept online in one place. Please follow link. http://www.bris.ac.uk/medical-school/staffstudents/assessments/students/
The COMP2 exam has 4 components:
An objective structured clinical examination (OSCE) - 50%
A written paper, which has a mixture of best-of-five multiple choice questions (MCQs) and extended matching questions (EMQs) - 40%
The Clerking Portfolio -10%
In order to pass the COMP2 unit you must pass each of these components. The OSCE exam is held twice per year and the written exam once per year. Students doing COMP2 in blocks 1 or 2 will do the OSCE exam after the end of block 2. Students doing COMP2 in blocks 3 or 4 will do the OSCE exam after the end of block 4. All students will do the written exam at the end of the academic year. The pass mark for the OSCE is calculated using the Borderline Regression Method. The pass mark for the written exam is calculated using the Angoff Method The pass mark for the Clerking Portfolio is 60/100. Your final mark for COMP 2 will be constructed as follows.
Component Accounts for (%) of the total assessment
Written Exam (MCQ/EMQ)
40
OSCE
50
Clerking Portfolio
10
TOTAL 100
DATES OF THE EXAMS
Blocks 1 & 2 Blocks 3 & 4
OSCE
Tuesday 21st January 2014 Tuesday 10th June 2014
Written paper
Friday 20th June 2014
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SEMINAR ON DISABILITY On Friday morning of week 9 you will have a seminar on Disability led by Dr David Memel, tutors with hearing and visual impairments, and several GP tutors. Learning Objectives
Understand the meaning and effects of disability for patients, carers, GPs and other members of the primary health care team
Be aware of the importance of functional, social and psychological, as well as medical factors in the assessment of patients in primary care
Appreciate the range of health, social and voluntary services available to people with disability in the community and how they are organised
Develop skills for the clinical management of patients with disabilities in the community Content of the Seminar There will be an introductory talk about disability issues, particularly as they apply to patients seen in primary care. You will then be divided into small group of about twelve students. The groups will be facilitated by GPs with an interest in disability issues. Tutors with hearing and visual impairments will talk about good communication You will have opportunities to practice consultation skills using role play with patients with hearing and visual impairments. You will be subdivided into groups of about four students to prepare and make presentations based on case scenarios emphasising different aspects of GP care on one of two topics:
Crisis in the Community-alternatives to hospital care
Sickness and welfare benefits You will be provided with extra resources on the day to help with your presentations. Preparation This seminar is part of the vertical ‘Disability’ theme that runs through the medical curriculum. It is worthwhile looking at your notes on the Disability Matters course that took place in the second year before this seminar, particularly:
a) Differences between the Medical And Social Models of Disability b) Experiences of Disability c) Communication with people with different disabilities
Notes to accompany this seminar are contained in the Primary Care Study Guide. This is essential reading beforehand. A lot of practical knowledge about the Medicine for disabled people in the community can be gained whilst you are sitting in with GPs in their practices and spending time with other staff. Here are a series of questions to think about, and ask your GP when you see relevant cases. Useful knowledge can also be gained during your Medicine for Older People placement.
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Questions 1. What are the different sorts of medical certificates that GPs give out? 2. What welfare benefits are patients receiving, and are they eligible for others? 3. What intermediate care services are available locally? 4. If there is a local community hospital, what services does it provide? 5. What is the role of the GP for patients with
a) Learning difficulties b) Chronic Mental Health Problems
6. Does your practice have a community matron, and what is his/her role? 7. How is the Medicine for patients with complex needs living at home coordinated
within the primary health care team
between primary and secondary care
between primary care, social services and voluntary organisations? 8. Collect examples of patients with complex needs who you think have good and poor care provided. Why
might this be?
9. How does the GP communicate with patients with different impairments eg. vision, hearing, speech, learning difficulties.
Further Reading 1. Simon, C, Everitt, H, Kendrick, T. Oxford Handbook of General Practice. 3rd Ed. Oxford: Oxford
University Press; 2009. Contains a lot of practical information including Benefits and Aids, Certifying Fitness to Work, Fitness to Drive.
2. Edited by Stephenson, A. A Textbook Of General Practice, 3rd Ed. London: Arnold; 2011
See Chapter 9: Chronic Illness and its Management in General Practice, and Chapter 10: Treating People at Home.
3. There is an excellent government website giving further information on all aspects of care for disabled
people: http://www.direct.gov.uk/DisabledPeople/fs/en
4. The Patient’s Journey. In the last few years there has been a very illuminating BMJ series of articles written by patients with chronic illnesses and disabilities http://www.bmj.com and search using keywords in the title ‘patient’s journey’
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ASSESSMENTS BLUEPRINT This page lists the methods used for assessing your acquisition of the learning objectives in COMP2
OSCE MCQ EMQ Clerking Portfolio
Primary Care
Describe the role of the GP, other members of the primary health care team and the other systems that provide open access health care in the UK
Conduct a complete consultation on any of the 16 core clinical problems listed (page 4). Including:
o Consulting effectively with a patient with a disability
o Identifying patients at risk of intimate partner violence and having strategies to help them
o Understanding how the delivery of bad news impacts on patients and carers
Describe the risks and benefits of commonly prescribed medication used in the treatment of these 16 core problems and understand the rationale behind making treatment decisions.
Help patient reduce their risk of developing chronic disease and use data interpretation e.g. blood pressure measurement and cardiovascular risk to inform management.
Describe methods by which the impact of disability on patients can be minimized
Dermatology
Take a dermatological history and explore a patient’s concerns and expectations
Examine the skin systemically (including palpation)
Describe and record findings using accepted dermatological terms
Recognise and appreciate the incidence and appropriate management of common skin disorders and skin cancers and be familiar with principles of topical therapy
Interact sensitively with people with skin diseases
Medicine for Older People
Describe common health problems in old age and their drug and non-drug management
In an older patient with complex physical and social problems who is hospitalised or residing in the community: Know the principals of Comprehensive Geriatric Assessment
Carry out a clinical assessment, construct working diagnoses
Define appropriate investigations and management plans
Name team composition, roles, processes and services meeting the specific patient and family needs
Perform and interpret the functional assessments commonly used in older people
Describe the processes of assessment and rehabilitation
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FEEDBACK You will receive feedback on your performance at many stages during and after studying COMP2
Throughout your GP attachments you will receive verbal feedback from your GP teachers. Please record this in the back of your study guide.
During each dermatology teaching session you will receive verbal feedback on your performance.
Throughout your Medicine for Older People attachment you will receive verbal feedback from your teachers. Please also seek feedback from the consultants to junior medical staff by prompting them as to how you can improve.
For the clerking portfolio, you will be asked to make your own self assessment and the tutor will then
mark your clerkings. You will be given structured feedback on areas for improvement.
At the end of the OSCE you will receive 2 minutes of verbal feedback from each examiner who assessed you. You are encouraged to record this feedback on a form that will be given to you.
In February 2014 or July 2014 you will be able to view your marks for the OSCE on Blackboard. You will have access to the following information:
Your mark for each OSCE station
The pass mark for each OSCE station
The mean mark for each OSCE station
In July 2014 you will be able to view a breakdown of all your marks on Blackboard. You will have access to the following information
Your score in each component of the written papers (Best-of-5s and Extended Matching Questions), broken down by element: Dermatology, Medicine for Older People and Primary Care
The pass mark for the written paper
The mean mark for each component of the written paper
All your marks for the OSCE
Your overall mark for COMP2
If you fail the COMP2, or if you only “just pass” one component of the exam, you will be invited to an interview with the Unit Lead to discuss your performance.
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TRAVEL You will have to do quite a lot of travelling during the COMP2 course. Students at Bristol If you are attached to one of the Bristol academies the only significant journey that you will have to make will be to your residential GP attachment (if you are assigned a residential placement). You will have to commute daily to your non-residential GP attachments in Bristol. If the GP surgery is outside the city limits then you should seek reimbursement from the academy. Your dermatology teaching will be at the BRI and your Medicine for Older People attachment will be at the BRI, BGH, Frenchay or Southmead. If you have a residential GP attachment, you can seek reimbursement for the cost of one return trip every 2 weeks to this GP practice from the Year 4 Admin Co-ordinator at the Curriculum Office, Senate House. If you return to Bristol for the middle weekend of the residential GP attachment you will have to pay for this yourself. You will not be expected to return to Bristol for dermatology teaching whilst on a residential GP attachment. Students at Bath, Somerset, Gloucestershire or Swindon If you are attached to the Bath academy, Somerset academy, the Gloucestershire academy or the Swindon academy you will be provided with accommodation on or near your hospital base. If this accommodation is more than 2.2 miles from the hospital base then the academy should provide free transport to the hospital or reimburse your travel costs. If you have any Dermatology or Medicine for Older People teaching outside the city limits and a free alternative is not provided then the academy should reimburse your travel costs. If you have a residential GP attachment, you can seek reimbursement for the cost of one return trip every 2 weeks to this GP practice from the Year 4 Admin Co-ordinator at the Curriculum Office, Senate House. If you return to Bristol for the middle weekend of the residential GP attachment you will have to pay for this yourself. You will have to commute to non-residential GP attachments from the accommodation that the academy provides for you. If the GP surgery is outside the city limits then you should seek reimbursement from the academy. The Faculty of Medicine and Dentistry at Bristol will reimburse you for one return trip to your academy accommodation from Bristol. If the course is interrupted by either the Christmas or Easter holiday, then you will be reimbursed you for an extra return journey. However, you will not be reimbursed for other return trips to Bristol that you might want to make at the weekends. You should contact the Year 4 Admin Co-ordinator at the Curriculum Office and complete the claim form at: http://www.bristol.ac.uk/medical-school/staffstudents/student/forms/claimform12-13.pdf You can find more information about travel expenses in the Faculty of Medicine and Dentistry book of “Rules, Policies and Procedures for 2013/14”.
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ADDITIONAL UNIT INFORMATION
DISTINCTIONS, MERITS AND PRIZES Merits and distinctions will be awarded on the basis of performance in these assessments. There will be no pass-fail vivas.
Prizes in COMP 2 A prize will be awarded to the student who attains the highest mark overall in the COMP2 exam.
Prizes in Primary Care The Glaxo Prize for Excellence in Primary Care is awarded at the end of the year to one student who has demonstrated the greatest aptitude for Primary Health Care whilst studying COMP2. The prize is worth £100.
The Nathan Burton Prize in Primary Care is worth £250 and is available each year for one student who would like to study Primary Care during their elective period. To apply for this prize please contact Dr David Memel in the Centre for Academic Primary Care. The successful candidate must submit a report of their elective. One winner of this prize spent her elective in the Shetlands and Wester Ross and gained insight into the unique aspects of practicing medicine in remote, rural areas. She wrote about the challenges of providing out-of-hours care in these areas and described how the interface between primary and secondary care in the Shetlands is different from that in other parts of the UK. The Royal College of General Practice (RCGP) also has an elective for medical students, worth £500. To apply for this prize you must contact Dr Memel in the Centre for Academic Primary Care. You can find more information about this prize at the following website http://www.rcgp.org.uk/brjgenpract.aspx
Prizes in Dermatology
The British Association of Dermatologists (BAD) Undergraduate Essay Prize is worth £500 and 3 prizes of £250. The 2009 title - 'A typical working day of a dermatologist in 2050' The BAD annually sets an essay title on a topic related to dermatology and offers prizes of £500 for the winning essay and three runners-up prizes of £250 each. The essay should be at least 3,000 words long. To access information see the BAD website www.bad.org.uk and follow links to Education and Fellowships.
Prizes in Medicine for Older People
The British Geriatrics Society (BGS) awards a number of prizes. There are two prizes of £500 each for an Elective. For full details, please see the BGS website: www.bgs.org.uk Look at the medical student section
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STUDENT ADVICE AND SUPPORT
For the names and contact details of tutors/administrative assistants see the section “Staff Information”. In Medicine for Older People for problems with the timetable or accommodation, first make contact with the tutor for that academy (or the administrative assistant working with the consultant). In Primary Care, the GP to whom you are attached should be the first person to contact if you encounter a problem. If the GP cannot help then please contact either the GP lead for your academy or Dr Jessica Buchan, the element lead for Primary Care. In Dermatology contact the tutor for that academy. Reverend Mr Nigel Rawlinson (Years 3-5) is available to discuss academic and welfare issues. Appointments can be made by contacting your administrative year co-ordinator, or via the booking calendar on the student advisor Blackboard course. Rev Mr Rawlinson can be contacted at [email protected] . You can find more information about the support mechanisms that are available to you by visiting the website www.bris.ac.uk/studenthelp.
REPORTING A CRITICAL INCIDENT Every effort is made to ensure that your teaching is conducted in a safe environment. However, hospital wards, GP surgeries and visits to patients in their own home, all present particular risks. If you are involved in an incident which has put your personal safety or health at risk please report this incident immediately to your teacher and to the person in charge of the element that you are studying at that time (Dr Shalini Narayan, Dr Sue Wensley, or Dr Jessica Buchan).
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ABSENCE POLICY Unplanned absence Please send ONE e-mail addressed to all the following people on the first day of unplanned absence: · [email protected] · the unit or academy manager who is expecting you · [email protected] (if you are on a GP placement)
the organiser of the central study day or planned event who is expecting you (if applicable) Please include the following information: · Name · current year · student number · reason for absence · expected length of absence · current academy/unit When possible, you should contact us before 9.30am. When returning from unplanned absence In line with University wide regulations and general NHS guidelines, if you are absent on health grounds for up to 7 consecutive days, you must submit: · an electronic self certificate form to [email protected] by e-mail by 5pm within 2
working days of your return from absence. If you are absent for more than 7 consecutive days, in addition to the above form, you must also submit: · a medical certificate by 5pm within 2 working days of your return from absence, a template for which can
be found with the self certificate form above. For more information, please see the University's guidance on student absence due to illness. Repeat absences and un-reported illness may prompt the Faculty to organise a meeting to discuss your health and well-being to ensure you are managing to cope and getting the support you need. Requests for leave (planned) Leave of absence requests relate to short periods of planned absence from the programme (normally no longer than three days up to an absolute maximum of two weeks) - you are advised to minimise time off particularly during clinical Units. Evidence may be requested, particularly for longer leave requests, or if you have already had long periods of absence. Clinical students: absences during the clinical years are likely to have a more serious impact on your learning than absences during pre clinical teaching as experiential learning is extremely important in clinical medicine. There may also be particular weeks/days where it is your only opportunity to receive teaching/experience in particular specialties. If your absence is not on health grounds or for a critical personal problem you should take this into consideration. Please note that if you take a long leave of absence during a unit, and then also have to take time off for illness, you may fail the unit due to non attendance. Please email the following information: Name Student number Year of study Reason for leave Date of leave (from – to), Number of days required
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Detail of teaching you will miss How you intend to make up this lost teaching time How many days leave (including illness) already taken in this academic year Attach any evidence or note any evidence that can be supplied
Send your email to: Years 1 and 2: the Pre-clinical Programme Director & your year administrative co-ordinator Years 3 - 5: your Academy Medical Dean (for Academy based teaching) - via the Academy
administrator or to your Unit Lead (for central teaching) – via the Unit administrator for External SSC Units: to the SSC Coordinator – via year 3 or year 4 co-ordinator
Any other teaching: Programme Director via relevant year administrative co-ordinator Please note leave of 5 days and over will need to be countersigned by the Director of Student Affairs, please allow time for this to happen. The Director of Student Affairs will follow-up on the welfare of any student who has had substantial time off. Evidence may be requested particularly for longer leave requests or if you have already had long periods of absence. Taking time from your course without notifying the Medical School is a professional behaviour issue.
ACCOMMODATION/RESIDENTIAL ATTACHMENTS GP attachments If you find yourself in a practice where you feel uncomfortable or unhappy, please phone or e-mail Dr Jessica Buchan or Melanie Butler. Medicine for Older People If there are problems with the timetable or accommodation, then contact the tutor for that academy, or their administrative assistant.
TUTORIAL SUPPORT Medicine for Older People One or two lead clinicians in Medicine for Older People will act as tutors in each of the clinical academies. You and the other students in this unit will meet your tutor regularly (weekly) to discuss how your studies are going. Primary Care The tutor role will be undertaken by the GP to whom you are attached.
PROFESSIONAL INDEMNITY You must have student membership of one of the medical defence organisations, either the Medical Defence Union or the Medical Protection Society. This costs nothing and ensures you have indemnity for professional activities in the non-NHS establishments such as some general practices and nursing homes.
STUDENT HEALTH AND SAFETY It is essential that, as soon as it is known, any student who has an existing or who develops any medical condition that may affect their ability to participate fully in the course of study should inform their supervisor. This will enable the student and the University to discuss and agree appropriate health and safety procedures to facilitate continued study. For further information see http://www.bristol.ac.uk/safety/media/po/safety-policy-po.pdf Please bring your Hep B certificate of vaccination with you to the Academies/GPs.
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MEDICAL STUDENT DRESS CODE FOR CLINICAL AREAS The Dress Code has three basic principles:
Patients should feel confident that they are being treated by a team of professionals. Your appearance is one part of ensuring patients have confidence in their carers.
All patients should feel their beliefs are respected. Ethnic origin, religious conviction and age group can influence patients’ views on appropriate dress. Patients should be made to feel as comfortable as possible in a clinical setting and inappropriate dress can cause unnecessary offence and upset.
Dress must conform to health & safety requirements for your protection and the protection of patients. In view of guidelines concerning infection control, a watch should not be worn on the wrist (due to bare below the elbow policies) but is acceptable on a waist band attached to shirt/blouse; short sleeves are preferred; if a tie is worn then it must be tucked in to the shirt.
As a general rule, in a clinical setting, men should wear a shirt & tie, with smart-casual trousers. Women should wear a blouse/smart top with smart-casual trousers or skirt, or a smart dress. Dress for areas such as Psychiatry and Child Health may be more casual but the following rules must always be followed:
Clothing should cover the body from the shoulder to the knee as a minimum. Bare midriffs are not acceptable.
Students should be aware that wearing sexually provocative clothing can be seen by some individuals as an invitation to make inappropriate and offensive comments/actions. This is particularly the case in areas such as A&E where patients and visitors may have been drinking and/or taking drugs. Students’ dress should therefore be of a conservative nature.
Clothing should be clean & pressed.
Shoes should be neat and clean. In your own interest, footwear should be comfortable to wear, but trainers are not acceptable. Wearing shoes with closed toes minimises the risk of injury to the feet.
Jewellery should be kept to a minimum. Dangling earrings and facial piercings are not appropriate.
Clothing should not restrict easy movement.
Clothing should not display prominent logos or pictures.
Combat-style trousers, jeans, and shorts are inappropriate.
Hair should be clean and tied back if long.
Your face should be fully exposed when working in all clinical areas. Head attire worn routinely for religious observances should not cover the face.
Hospital attire (e.g. scrubs) should be worn where this is required by the Trust/Ward.
You should always have your identity badge prominently displayed.
Note these rules apply to the clinical working environment. However, if you are entering any clinical area for any teaching activity, including assessments involving patients, you should ensure that your dress will not cause offence to staff, patients or visitors.
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