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Physician Assistant Program

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  • 1. Physician Assistant Program Guidelines and Policies Class of 2010 2008 – 2010 REVISED 8/2008 All information found in this handbook is subject to change. Please contact the Physician Assistant Program at (208)282-4726 with any questions or concerns. 1
  • 2. Table of Contents Introduction 5 ISU PA Program Overview 6 The Mission 8 Curriculum 9 Didactic Curriculum 9 Clinical Curriculum 10 General Policies and Guidelines 11 ISU Policies and Guidelines 11 Family Educational Rights and Privacy Act 11 Americans With Disabilities 11 ADA and Disabilities Resource Center 12 ISU Policy and HIPAA 12 1. Academic Standing and Grades 12 Progression through PA Curriculum 12 Transfer of Credits 12 Time Limits 12 Final Program of Study 12 Application for a Degree 12 Graduation Requirements 13 Academic Progression/Dismissal 13 Academic Affairs Committee 13 Repeated Courses and Auditing Courses in the PA curriculum 13 Professional Behavior 14 2. Withdrawal or Dismissal 16 3. Appeals of Grade or Dismissal 17 4. Academic Dishonesty 21 5. Employment Policy 22 Didactic Year Policies and Guidelines 23 6. Didactic Year Attendance 23 7. Evaluation of Student Performance 23 8. Learning Objectives 25 9. Tutoring 25 10. Didactic Year Clinical Experiences 26 11. Entrance into Clinical Year 26 Background Checks 26 Capstone Experience 27 12. Capstone Experience, Masters Project in PA Studies course description 27 Comprehensive Examination 27 Case Presentation 27 Advisors and Committee 27 Conflict of Interest of Graduate Faculty 27 Written Report 28 2
  • 3. Oral Defense 27 Portfolio 28 Failure of portion of capstone event 31 Continuing Registration for Graduate Students 31 Introduction to the Clinical Year 33 Maximizing your clinical experience 33 Clinical Year Policies and Guidelines 34 13. Clinical Rotation Information 34 ISU Catalog Descriptions 34 Clinical Rotations I-VIII Overview 34 End of Semester Meetings 34 Rotation Change Policy 34 Out-of-area site policy 34 Personally arranged sites 35 Preceptorship Policies 35 Rotation Selection 35 14. Travel Funds 36 15. Clinical Year Attendance 36 16. Academic Standards 37 Grading Criteria 37 Good Academic Standing 38 End-of-Rotation Exams 38 Makeup Examination 38 Student Name Tag 38 Professional Appearance 39 Supervision 40 Incident Reports 40 17. Progression from Clinical Year to Graduation 41 18. Information for Preceptors 42 19. Clinical Year Objectives 47 Part I - PA Program Outcome Objectives 48 Part II - General Clinical Year Objectives 49 Part III - Specific Clinical Rotation Objectives Primary Care Rotations 54 Outpatient and Inpatient 54 Obstetrics and Gynecology 66 Pediatrics 71 Part III - Specific Clinical Rotation Objectives Specialty Care Rotations 76 Surgery 76 Psychiatry 82 Emergency Medicine 87 Part III - Specific Clinical Rotation Objectives Elective Rotations 90 Cardiology 90 3
  • 4. Dermatology 94 ENT 99 Orthopedics 103 20. Clinical Year Evaluations Policies 108 21. Clinical Evaluation Forms 109 Preceptor Forms Mid-Rotation Preceptor Evaluation Form 110 Final Preceptor Evaluation Form 111 Faculty Forms: Mid-Rotation Site Visit Form 116 Evaluation of Case Presentation 117 Student Forms: Site Evaluation 120 22. Appendices 124 Appendix A: Guidelines for Ethical Conduct 124 Appendix B: Needle Stick/Bloodborne Pathogen Exposure Policy 134 Appendix C: Medicare Reimbursement Guidelines for Students 135 Appendix D: Competencies for the Physician Assistant Profession 140 4
  • 5. Introduction There are numerous components to the concept of professionalism. Not all of them can be enumerated in this guide. However, the Program faculty has identified areas of behavior and activity which it deems essential for student compliance. Expectations are identified which address academic and professional criteria for successful completion of the physician assistant course of study. As a PA student, you are expected to be completely cognizant of such expectations and will be evaluated on the basis of your compliance with them. The information contained in these Policies and Guidelines is consistent with the Idaho State University Graduate Catalog, the Accreditation Review Commission on Education for the Physician Assistant, Inc. (ARC-PA) Standards and the National Commission on Certification of Physician Assistants (NCCPA). 5
  • 6. ISU PA Program Overview Definition of A Physician Assistant (PA) Physician assistants are health professionals licensed to practice medicine with physician supervision. Physician assistants are qualified by graduation from an accredited physician assistant educational program and/or certification by the National Commission on Certification of Physician Assistants. Within the physician/PA relationship, physician assistants exercise autonomy in medical decision- making and provide a broad range of diagnostic and therapeutic services. The clinical role of physician assistants includes primary and specialty care in medical and surgical practice settings in rural and urban areas. Physician assistant practice is centered on patient care and may include educational, research and administrative activities. Services performed by physician assistants include, but are not limited to: - Evaluation - Eliciting a detailed medical history, performing an appropriate physical examination, delineating problems, and recording information in the medical record. - Monitoring - Assisting the physician in developing and implementing patient management plans, recording progress notes in office-based and patient health care settings. - Diagnostics - Performing and interpreting (at least to the point of recognizing deviations from the norm) common laboratory, radiologic, cardiographic, and other routine diagnostic procedures used to identify pathophysiologic processes. - Therapeutics - Performing routine procedures such as injections, immunizations, suturing and wound care, managing simple conditions produced by infection or trauma, participating in the management of more complex illness and injury, and taking initiative in performing evaluation and therapeutic procedures in response to life-threatening situations. - Counseling - Instructing and counseling patients regarding compliance with prescribed therapeutic regimens, normal growth and development, family planning, situational adjustment reactions and health maintenance. - Referral - Facilitating the referral of patients to the community’s health and social service agencies when appropriate. The extent of the involvement by physician assistants in the assessment and treatment of patients depends largely on the complexity and acuity of the patient’s condition as well as their training, experience, and preparation as assessed by the supervising physician. The Profession 6
  • 7. Physician Assistants (PAs) are academically and clinically prepared to provide healthcare services, including the diagnosis and treatment of disease, with the direction and responsible supervision of a doctor of medicine or osteopathy. The physician-PA team relationship is fundamental to the PA profession and enhances the delivery of high quality health care. PAs make clinical decisions and provide a broad range of diagnostic, therapeutic, preventive, and health maintenance services. The clinical role of PAs includes primary and specialty care in all medical and surgical practice settings. PA practice is centered on patient care and may include educational, research and administrative activities. Nationwide, the starting salary for PA graduates ranges from approximately $55,000 - $101,000 per year. The role of the PA demands intelligence, sound judgment, intellectual honesty, appropriate interpersonal skills, and the capacity to react to emergencies in a calm and reasoned manner. An attitude of respect for self and others, adherence to the concepts of privilege and confidentiality in communicating with patients, and a commitment to the patient’s welfare are essential attributes of the graduate PA. The Program The Physician Assistant (PA) Program at Idaho State University awards the Master of Physician Assistant Studies (MPAS) degree and a PA certificate upon successful completion of its 24 month graduate curriculum. A class of 50 students is enrolled each fall semester. Application to the Program is through the Central Application Service for Physician Assistants (CASPA). The Program is fully accredited by the Accreditation Review Commission on the Education of Physician Assistants, Inc., ARC-PA. Graduates of this Program are eligible to take the NCCPA’s Physician Assistant National Certifying Exam (PANCE). 7
  • 8. The Mission The mission of the Idaho State University Physician Assistant Program is to: Curriculum: Provide a quality graduate medical education that emphasizes critical thinking and problem solving, is technologically enhanced, research oriented, and evidence-based, with strength in both the basic and clinical medical sciences. Students: Seek a culturally, ethnically, and socially diverse student body which will demonstrate the finest attributes of professional health care practitioners, including intellectual curiosity, insight, maturity, ethical behavior, critical thinking, empathy, strong interpersonal skills, a service orientation, and a commitment to evidence-based practice, research and lifelong learning. Faculty: Employ, develop and maintain outstanding faculty who are appropriate in expertise and number to the needs of the Program, represent the diversity of the nation, are student-centered and committed to the educational needs of the students as well as excellence in teaching, scholarly research, service, and continuing clinical competence. Affiliations: Establish and maintain, for the educational benefit of program students, clinical, educational, and other relationships with the medical community and other individuals and organizations that seek to enhance health care to rural and other medically underserved populations of the State, region, and beyond. Service: Nurture in students sensitivity to the needs of others and a desire and willingness to provide service of the highest quality, in the most caring manner, to all people, especially to those individuals and groups that are medically underserved, regardless of biological, social, political, economic, religious, or other status. 8
  • 9. Curriculum The ISU PA Program graduate curriculum is twenty-four (24) months in length, divided into twelve (12) months of didactic and twelve (12) months of supervised clinical education. Each class progresses through the curriculum as a cadre. There is no part-time option. The fall semester of the didactic curriculum is comprised of foundation courses, followed by modules in the spring semester and summer session that provide an immersion experience in the diagnosis and treatment of diseases commonly encountered in primary care medicine. DIDACTIC CURRICULUM Fall Semester: BIOS 529 Regional Anatomy and Histology PAS 601 Intro to Physician Assistant BIOS 564 Lectures in Human Physiology PAS 602 Research Methods BIOS 563 Human Pathophysiology PAS 603 Clinical Assessment PAS 604 Pharmacology Spring Semester: PAS 630 Allergy/Immunology Module PAS 637 Gastroenterology Module PAS 631 Infectious Disease Module PAS 638 ENT Module PAS 632 Hematology/Oncology Module PAS 640 Rheumatology Module PAS 633 Endocrinology Module PAS 641 Orthopedics Module PAS 634 Renal Module PAS 642 Psychiatry Module PAS 635 Pulmonology Module PAS 645 Ophthalmology Module PAS 636 Cardiology Module Summer Semester: PAS 639 Dermatology Module PAS 652 Geriatrics Module PAS 646 Neurology Module PAS 653 Surgery Module PAS 647 Human Sexuality Module PAS 654 Emergency Medicine Module PAS 648 Women’s Health Module PAS 656 Alternative/Occupational PAS 649 Men’s Health/Urology Module Medicine Module PAS 650 Obstetrics/Perinatology Module PAS 657 Comprehensive Evaluation PAS 651 Pediatrics Module 9
  • 10. CLINICAL CURRICULUM Fall Semester: PAS 660 Clinical Rotation I: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. PAS 661 Clinical Rotation II: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. PAS 662 Clinical Rotation III: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. PAS 669 End of Semester Meeting I: Students will participate in a 2-day meeting. Lectures and other content in primary care, specialty care and professional development content will be delivered. Cumulative end of semester assessments will be given. Spring Semester: PAS 663 Masters Project in Physician Assistant Studies: An evidence-based medical case study, completed under the direction of the program faculty. A written report and oral explication of the case study is required. PAS 664 Clinical Rotation IV: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. PAS 665 Clinical Rotation V: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. PAS 666 Clinical Rotation VI: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. PAS 670 End of Semester Meeting II: Students will participate in a 2-day meeting. Lectures and other content in primary care, specialty care and professional development content will be delivered. Cumulative end of semester assessments will be given. Summer Semester: PAS 667 Clinical Rotation VII: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. PAS 668 Clinical Rotation VIII: Supervised clinical practicum in primary care and/or specialty care in medical practice settings. 10
  • 11. General Program Policies and Guidelines ISU POLICIES AND GUIDELINES Federal Family Educational Rights and Privacy Act of 1974 Idaho State University in compliance with the Family Educational Rights and Privacy Act (FERPA), is responsible for maintaining educational records and monitoring the release of information of those records. Staff and faculty with access to student educational records are legally responsible for protecting the privacy of the student by using information only for legitimate educational reasons to instruct, advise, or otherwise assist students. Only those records defined as "directory information" may be released without the express written permission of the student. Directory information includes the student's name, address listings, telephone listings, e-mail addresses, full-time/part-time status, class level, college, major field of study, degree types and dates, enrollment status, club and athletic participation records, and dates of attendance including whether or not currently enrolled. No other information contained in a student's educational records may be released to any outside party without the written consent of the student. A student may restrict release of all directory information by filing a Declaration of Non-disclosure of Educational Record Information form in the Office of Registration and Records. Student may choose to restrict release of their address and telephone listings only. This may be done through their MyISU portal by accessing the Student Address Change Request form under Student Records information. This restriction will apply to the students' address and telephone listings only; all other directory listings will continue to be available for release. Students must request complete directory information restriction or address/phone listing restrictions during the first week of fall term to prevent their information from being published in the Student Directory. Any restriction is permanent and remains in place even after the student has stopped attending or has graduated from the University unless the student requests, in writing, that it be removed. Additional FERPA information may be found on the web at: http://www.isu.edu/areg/ferpafacts.shtml Americans with Disabilities Statement on Compliance and Services The Americans With Disabilities Act (ADA) is the civil rights guarantee for persons with disabilities in the United States. It provides protection from discrimination for individuals on the basis of disability. The ADA extends civil rights protection to people with disabilities in matters which include transportation, public accommodations, accessibility, services provided by state and local government, telecommunication relay services, and employment in the private sector. Idaho State University, in the spirit and letter of the law, will make every effort to comply with “reasonable accommodations”, according to section 504 of the Rehabilitation Act of 1973 and the Americans With Disabilities Act. Idaho State University will not discriminate in the recruitment, admission, or treatment of students or employees with disabilities. Students and employees who need auxiliary aids 11
  • 12. or other accommodations should contact the ADA & Disabilities Resource Center, Campus Box 8121, (208) 282-3599. ADA and Disabilities Resource Center Students with disabilities who wish to have accommodations provided by the University must self identify in order to have accommodations provided. Information and applications for accommodations are available in the Center and may be picked up in person or requested by telephone or TDD by calling (208) 282-3599. In order for the Center to arrange accommodations for those who need assistance, they request notification as early as possible so that timely arrangements can be made. ISU Policy and HIPAA “The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1999. ISU is committed to protecting the confidentiality of protected health information and in complying with Federal and State regulations regarding protected health information.” 1. ACADEMIC STANDING AND GRADES A. Progression through PA Curriculum: i. The Physician Assistant curriculum is a progressive immersion experience and each class of students is expected to move through the curriculum as a cohort. B. Transfer of Credits: i. Transfer of credits from other programs is not permitted. C. Time Limits: i. The field of medicine is continually advancing, therefore all requirements for an MPAS degree must be completed within 4 (four) years. D. Final Program of Study: i. A final Program of Study must be submitted to and be approved by the Graduate School during the semester immediately preceding the semester in which the student intends to graduate (typically during the Spring semester). ii. The Program will initiate the required forms for the Program of Study. iii. The final Program of Study form will list all requirements that must be completed in order to receive the degree or certificate. E. Application For a Degree: i. Within the first two weeks of the fall or spring semester in which the student expects to complete work for the degree, or the last day of spring semester for graduation during summer session, an application for graduation must be filed with the Graduate School. ii. An application and diploma fee must be paid at this time in the Office of Registration and Records. Check the Graduate Catalog for the fee amount (http://www.isu.edu/catalogs.shtml) iii. If the student does not complete requirements during this semester or summer session, an updated application must be submitted for the subsequent semester 12
  • 13. and a reprocessing fee paid to the Graduate School. Check the Graduate Catalog for the reprocessing fee amount (http://www.isu.edu/catalogs.shtml). iv. Applications for degrees will not be approved without the prior approval of a final Program of Study form. F. Graduation Requirements: i. In order to graduate from the PA Program, a. Students must successfully complete all program requirements for the didactic and clinical years. b. Students must meet all requirements of the Graduate School. c. Throughout the Program, students must possess a cumulative grade point average (GPA) of 3.0 for all course work undertaken as part of the Physician Assistant Program. G. Academic Progression/Dismissal: i. Any student who receives a grade of C+ or below for any one course in any given semester must petition the PA Program Academic Affairs Committee (AAC) in order to continue in the Program. ii. If a student receives a grade of C+ or below in more than two courses/modules in the Program, the student will be academically dismissed from the Program, regardless of GPA. iii. Grades will be reviewed by the Academic and Clinical Coordinators at the end of each semester. a. Students whose cumulative grade point average falls below 3.0 may be placed on academic probation for the following semester. b. If the student fails to achieve an overall cumulative average of 3.0 after one semester of probation, the student may be academically dismissed from the Program. iv. Deviations from these standards must be approved by the PA Program Academic Affairs Committee (AAC) through formal petition by the student. H. Academic Affairs Committee (AAC): i. The AAC shall be convened in order to deliberate student appeals in those cases where a student falls out of good standing, either academic or behavioral, as per this manual. ii. The purpose of the AAC is to provide a recommendation to the Program Director based on the student’s files, petition to continue, facts and information presented, and demonstrated potential to successfully complete the Program. iii. The AAC will be comprised of a minimum of three faculty appointed by the Program Director. This Committee will meet as soon as possible in order not to impede the academic progress of students who may continue in the Program. I. Repeated Courses and Auditing Courses in the PA curriculum: i. The curriculum is an immersion experience, and all students are expected to move through the Program as a cohort. ii. Students who have previously taken courses that are part of the Program curriculum may petition the AAC to audit the class(es). a. Students who are auditing a class are expected to attend lectures and otherwise meet all course objectives. b. Audits are not allowed if content, labs, or small groups/discussions vary from that required by the program’s objectives. 13
  • 14. J. Professional Behavior: In addition to meeting minimum grade requirements, students must adhere to standards of professional behavior which include, but are not limited to the following Professional Behavior Performance Criteria: i. Successful completion of the program is dependent upon compliance with professional behavior criteria as well as academic performance. These criteria include, but are not limited to, consistent demonstration of: a. Mature demeanor, manner, conduct, behavior, character, deportment, and performance. b. Evidence of respect shown for patients, preceptors, staff, instructors and fellow students; c. Personal integrity and honesty; d. Sensitivity to patients and respect for their rights to competent, confidential service. ii. Examples of unprofessional behavior include, but are not limited to, the following: a. Failure to comply with Program regulations and rules; b. Failure to participate fully in all aspects of the curriculum. 1) If a student believes that full participation in this professional curriculum is not possible, it is the student’s responsibility to notify the program faculty immediately or as soon as the student is aware that there is a limitation. 2) Failure to participate fully in all aspects of the curriculum or failure to notify program faculty in a timely manner of the inability to fully participate may result in disciplinary action, including dismissal. c. Failure to accept and act upon constructive criticism; d. Attendance problems: including failure to notify the instructor, the clinical site, and/or the program; chronic absences; leaving early; etc. 1) Absences will be recorded. 2) Students are required to attend and participate in all scheduled activities. 3) Classes and/or clinical experiences may include involvement on any day of the week, weekends, evenings, holidays, as well as being on-call. 4) Anticipated absences must be requested on-line, and discussion with the appropriate faculty member must take place before the absence. 5) Voice mail messages are not adequate notice of an anticipated absence. Students must always talk personally with a faculty member and preceptor (for clinical rotations) if a student is going to be absent. (Refer to 6A.-D. for Didactic Year, and 15A.-D. for Clinical Year) 6) Not showing up for class, without prior approval, will be an absence. 7) Leaving the classroom during class will be counted as an absence. 14
  • 15. e. Lateness/tardiness: including failure to immediately notify the instructor, clinical site, and/or the program; 1) Tardiness will be recorded. 2) Tardiness (late entering the classroom and taking your seat) will be recorded as an absence. f. Failure to follow protocol or directions of supervising preceptor or Program faculty; g. Performing unauthorized procedures or administering services which are not permitted by the program, supervisor or facility; h. Lack of cooperation with faculty, preceptors, lecturers, and fellow students; i. Electronic Device Use: Laptop use during class must be solely for academic purposes, not for email, games, or other on-line activities unrelated to the class. EXCEPTION: To email or message Brian, Jerry, or Chad regarding technical problems during the lecture, e.g., “The volume is too high/low,” “The picture is out of focus,” etc. 1) Access to pornography using the University internet connection, while in an academic or clinical setting, or while on University property is a violation of professional standards and may result in dismissal from the program. 2) Your use of your computer or other electronic devices must not be a distraction to other students during lecture. 3) Cell phones must be OFF (not even vibrate) during lectures. Emergency calls must come through the program phones during a lecture. 4) Cell phones can be used during breaks, between lectures. Leaving a lecture to make or take a cell phone call is considered unprofessional. j. Hostile, disruptive and passive-aggressive attitudes and behaviors; k. Quizzes and Tests: 1) MUST be taken in the classroom unless determined otherwise by appropriate faculty. 2) You may only have one piece of paper and a pen, no other windows may be open on your computer, and all books/back packs must be outside of the classroom. 3) Absolute silence must be maintained in the classroom during examinations. 4) Copying exams or quizzes, by any methodology, is forbidden and will be treated as Academic Dishonesty as defined by the University. l. Evaluations of Program and Courses: 1) Must be professional in criticism. 2) Unprofessional comments and language will be deleted. m. Violating patient confidentiality; n. Not respecting the rights of patients; 15
  • 16. o. Avoiding, or failing to perform, or only partially performing, assigned tasks and responsibilities; p. Leaving the clinical setting without informing the supervising preceptor or program representative; q. Performing any activity which is beyond the scope of the role of a student or beyond a student’s clinical ability; r. Failure to properly identify yourself as a physician assistant student; s. Failure to inform a patient who refers to you as “doctor” of your identity as a physician assistant student; t. Failure to report all observed unethical conduct by other members of the health profession and/or fellow students to Program faculty; u. Associating professionally with those who violate ethical practices; v. Endangering the health and welfare of any patient. iii. Violations of professional behavior policy and possible outcomes: a. Based upon the nature and degree of the precipitating events, students who fail to maintain appropriate behavior, will, as previously described above, be subject to the following disciplinary actions: 1) If a violation of the professional behavioral policy is deemed to have occurred, the Program faculty will meet with the student and issue a verbal warning regarding the behavior with written documentation to the student’s file. 2) THREE (3) WARNINGS ON ANY OF THESE BEHAVIORAL MATTERS WILL RESULT IN THE STUDENT BEING REFERRED TO THE PROGRAM’S ACADEMIC AFFAIRS COMMITTEE. Possible results from the review may include the following: a) No action taken; b) A written warning being given the student and the student being placed on academic probation with written documentation to the student’s file. c) Dismissal of the student from the program. 2. WITHDRAWAL OR DISMISSAL A. PA Program students may not withdraw from a required course without permission from the Program Director. i. Withdrawal from a required course without permission may, at the discretion of the AAC, necessitate dismissal from the Program. B. Students may voluntarily withdraw from graduate courses until the official drop date listed in the Academic Calendar at the front of the Graduate School Catalog. In such cases, the student must provide written request for the withdrawal by use of the appropriate withdrawal forms. Students wishing to withdraw from graduate courses or from a graduate program after the official drop date must obtain approval of the Dean of Graduate Studies. Withdrawal from courses must occur prior to final examination week. Voluntary withdrawal from a graduate program during an appeal of dismissal automatically terminates the appeals process. 16
  • 17. C. Students receiving letters of dismissal will automatically be dropped from all graduate courses, regardless of whether they choose to appeal, and fees will be refunded in accordance with University policy. i. A "W" grade will then be entered on the transcript for all graduate courses not completed. ii. Students receiving dismissal letters after the 10th day of classes may petition the Dean of Graduate Studies for permission to complete the graduate courses in which they are enrolled. iii. Students who appeal the dismissal will be blocked from registration for further graduate courses during the appeals process itself. iv. See also the Graduate School Catalog section entitled “Appeal of Dismissal”. D. A graduate student may be dismissed from a graduate program by a department/college according to the policy described in the Appeal of Dismissal section of the Graduate School Catalog. 3. APPEALS OF GRADE OR DISMISSAL A. Appeal of a Grade i. Midterm grades are not official and may not be formally appealed. Students who wish redress for midterm grades should discuss the grade with the instructor of the course in order to determine a course of action leading up to the final grade. Graduate students who wish to appeal final grades must use the following procedural format. Appeal of a grade must be made within one semester following the posting of the grade. Grades earned in the spring semester that are to be appealed need not be appealed during the summer, but the appeals process must be initiated in the following fall semester. Faculty members who are overruled in the appeals process are entitled to the same sequence of appeal as the graduate student. Documentation of the appeal must be sent to the Graduate School to be placed in the student's file. The Graduate School encourages resolution of appeals at the lowest possible level. When a grade appeal involves plagiarism, cheating, or other academic dishonesty, please also refer to the "Academic Dishonesty" section of the Graduate Catalog. ii. Procedures for the Appeal of a Grade a. Step 1: The Instructor of the Course When a student receives a grade that is judged by that student to be unjustifiably low, the first step in the appeals process is to discuss the matter with the instructor of the course. This may be done informally, but if the student plans to proceed up the line of appeal, a formal statement must be prepared in accordance with the format presented in the "Protocol for Appealing a Grade," which is described below. If the instructor agrees that the student was erroneously graded, the grade is changed using standard procedures. If the instructor stands by the original decision, the case may be taken to the department chairperson. In such an instance, the instructor must prepare a statement explaining the reasons for the grade. 17
  • 18. b. Step 2: The Department Chairperson The chairperson of the department in which the appealed grade was received is to review the student’s written statement and the instructor’s written rationale for the grade. The chairperson should interview the student and the instructor and may conduct whatever additional investigation is deemed appropriate to help in the decision-making process. The chairperson must render a decision within two weeks of receipt of the appeal. If the chairperson sustains the decision of the instructor, the appeal may be taken to the dean of the college. If the department chairperson chooses to overrule the instructor, the grade must be adjusted and the chairperson may adjust the grade. It is possible to negotiate the adjusted grade. If the student remains dissatisfied with the adjustment, the appeal may still be taken to the dean of the college. Regardless of the decision, the chairperson must prepare a statement, in writing, that explains the reason for the decision. If the appeal is taken to the dean, the chairperson’s statement must accompany the student’s appeal and the instructor’s statement. c. Step 3: The Dean of the College The dean of the college is next to be contacted in the appeals process. The dean is to appoint an impartial committee of faculty members who will review all written documentation pertaining to the case. This appeals committee should interview both the student and the instructor and may conduct any other investigation deemed necessary. The appeals committee, which is advisory to the dean, must submit a written statement of its decision. The dean’s decision is also to be tendered in writing. The committee’s deliberation and the dean’s decision must be completed within three weeks of receipt of the appeal in the dean’s office. If the student is not satisfied with the decision of the committee, the appeal may be taken to the Graduate Council. d. Step 4: The Graduate Council via the Dean of the Graduate School At the request of the student, the Graduate Council will review all prior documentation and render a decision within three weeks of receipt of the appeal. The Dean of the Graduate School and/or the Graduate Council may interview the student and instructor or carry out any other investigation deemed necessary to assist in the decision-making process. Once the decision is made, it is final and will be implemented by the Dean of the Graduate School. B. Protocol for Appealing a Grade i. Protocol for appeal of a grade must include the student’s name, department/college, date of the appeal, course title and number, instructor’s name, and grade received in the course. Also included must be the student’s rationale for appeal of the grade. The student should state as succinctly as possible the reasons for making the appeal. The student must also state the remedy he/she is seeking. C. Dismissals i. Dismissal Policy: A graduate student may be dismissed from a graduate program by a department/college according to the following criteria: 18
  • 19. a. If the student receives two or more grades of C+ or below, or b. If the student fails to meet the continuation standards of the department (including conditions stated on the Approval for Admission form), or c. If it is the academic judgment of two-thirds of the graduate faculty in the department that the student is not making satisfactory progress in the program, and such judgment is recorded by formal vote. In all cases the student must be notified in writing by certified mail, return receipt requested, that he/she is dismissed and must be told in the document that he/she has the right of appeal according to the ISU Graduate Catalog. The student should be given a copy of the Graduate Catalog or notified that the Catalog is available online or in the Graduate School. Students receiving letters of dismissal will automatically be dropped from all graduate courses in the program from which they are being dismissed, regardless of whether they choose to appeal; fees will be refunded in accordance with university policy. A "W" grade will then be entered on the transcript for all graduate courses not completed. Students receiving dismissal letters after the 10th day of classes may petition the Dean of the Graduate School for permission to complete the graduate courses in which they are enrolled. Students who appeal the dismissal will be blocked from registration for additional graduate courses during the appeals process. See "Procedures for the Appeal of Dismissal from a Graduate Program," below. The initiation of the appeal must occur within 15 working days of the notification of the dismissal, unless the student is appealing dismissal due to receiving two or more grades of C+ or below. In that case, the student may wish to appeal one or more grades before beginning appeal of dismissal (see "Appeal of a Grade" section). If the grade is upheld, and the student now wishes to appeal the dismissal, the student must begin the appeal of dismissal within 15 working days of the notification of the decision of the grade appeal. If the grade is changed to a B- or above, and the student no longer has two or more grades of C+ or below, the dismissal will be cancelled by the department/college. However, if the dismissal is also based on items b or c, above, the dismissal proceedings may continue. Documentation of the appeal must be sent to the Graduate School to be placed in the student's file. The Graduate School encourages resolution of appeals at the lowest possible level. When a dismissal involves plagiarism, cheating, or other academic dishonesty, please also refer to the "Academic Dishonesty" section of the Graduate Catalog. D. Procedures for the Appeal of Dismissal from a Graduate Program i. Step 1: The Departmental Level a. The student must request reconsideration in writing using the "Protocol for Appealing Dismissal from a Graduate Program," which is described below. b. A majority of the graduate faculty of the department must meet within 15 working days of the filed appeal and must decide by a 2/3 vote of those present to sustain the dismissal, or the dismissal is revoked. If necessary, the meeting of the graduate 19
  • 20. faculty may include those participating by telephone or video conference. Should it prove impossible during the summer to convene a majority of the graduate faculty, the department is required to assemble them in the first week they are on contract in the fall semester. In such instance, if the student chooses to appeal the department’s graduate faculty decision, the dean of the college and the Graduate Council will attempt to expedite the procedure described below. c. Either decision (revoke or sustain) is to be explained in writing to the student. Copies of this decision and explanation should be sent to the Dean of the Graduate School. d. If the department upholds the dismissal, the student may appeal the decision to the dean of the college. The student must appeal to the dean of the college within 15 working days of the notification of the department’s decision. e. If the dismissal is revoked, the department chairperson shall notify in writing the student and the Dean of the Graduate School, and the student shall be reinstated. ii. Step 2: The Dean of the College a. If the student appeals to the dean of the college, then the dean must do the following: 1) Read the student’s written statement. 2) Read the written decision and explanation of the graduate faculty of the department. 3) The dean may interview the student or the graduate faculty in the department or conduct any other appropriate investigation that may aid in the decision- making process. 4) The dean must consider the appeal within 15 working days of the student’s filed appeal and must decide to either revoke or sustain the dismissal. b. Dean Overrules Dismissal. If the dismissal is revoked, the dean must state in writing the reasons for the overrule and notify the student, the department, and the Dean of the Graduate School, and the student shall be reinstated. The graduate faculty of the department may appeal the dean’s decision to the Graduate Council. c. Dean Sustains Dismissal. If the dean sustains the decision to dismiss, he/she must notify in writing the student, the department, and the Dean of the Graduate School. iii. Step 3: The Graduate Council via the Dean of the Graduate School a. The student may appeal to the Graduate Council if the dean of the college sustains the dismissal. The student must appeal to the Graduate Council within 15 working days of the notification of the dean’s decision. This appeal must be in writing. b. The Graduate Council must consider the appeal within 15 working days of the student’s notification of appeal. This 20
  • 21. review should include copies of documents prepared in Step 1 and Step 2 of the appeal process. c. The Dean of the Graduate School and/or the Graduate Council may interview the student, graduate faculty, or college dean to secure whatever information might be deemed necessary to aid in the review. d. The Council’s decision to revoke or sustain the dismissal is final. e. The Council’s decision is to be pre pared in writing, and, with all other documentation, kept in the student’s file in the Graduate School. f. The Dean of the Graduate School must notify in writing the student, department, and college dean of the decision. g. If the decision is to revoke the dismissal, the Dean of the Graduate School must reinstate the student in the program. E. Protocol for Appealing Dismissal from a Graduate Program Protocol for appeal of dismissal from a graduate program must include the student’s name, department/college, and date of the appeal. Also included must be the rationale for appeal of the dismissal. The student should state as succinctly as possible the reason for making the appeal. The student must also state the remedy he/she is seeking. 4. ACADEMIC DISHONESTY A. Academic dishonesty includes, but is not limited to, cheating and plagiarism. Copying, electronic copying, distribution and reproduction of academic material without proper written consent will also be considered academic dishonesty. (Examples of academic material include, but are not limited to, testing and quiz content, course material, presentation files, etc.) Academic dishonesty at the graduate level is considered a serious offense and may result in dismissal from a graduate program. B. Whenever a faculty member suspects a graduate student of academic dishonesty, the instructor should present the evidence to the student and consider the student's response. C. If the instructor concludes after consultation with the student that academic dishonesty has indeed occurred, the instructor should write a letter to the chairperson of the department in which the student is seeking a graduate degree, describing the incident. D. The instructor should include with the letter any evidence used to draw the conclusion that academic dishonesty has occurred (e.g., copies of the student's written assignment, copies of documents thought to have been plagiarized, etc.), and should state clearly the penalty imposed within the course itself. E. The penalty should be in proportion to the severity of the offense. i. If the penalty is to be a failing grade, the instructor should first consult with the chairperson of the department, and the chairperson should meet jointly with the student and faculty member to review the incident. F. The student may appeal the penalty by following the procedures in the Graduate Catalog entitled "Appeal of a Grade." 21
  • 22. G. A copy of the instructor's letter reporting the offense, along with any evidence submitted to the chairperson, should be sent to the student, to the dean of the college in which the student is seeking a graduate degree, and to the Dean of Graduate Studies. i. A copy of the letter is to be placed in the student's permanent file in the department and in the Office of Graduate Studies. ii. If the student is exonerated during the appeals process, however, the letter and all other records of the accusation of academic dishonesty are to be deleted from the student's files. H. The department chairperson may, in accordance with the policy and procedures of the department, impose the penalty of dismissal from the program. i. A student may appeal the dismissal by following the procedures in the Graduate Catalog entitled "Appeal of Dismissal from a Graduate Program." 5. EMPLOYMENT POLICY A. Employment in the didactic portion of the program is discouraged. B. Employment in the clinical portion of the program is not permitted. 22
  • 23. Didactic Year Policies and Guidelines 6. DIDACTIC YEAR ATTENDANCE A. As stated in the Program Policies & Guidelines (Sections 1.J.ii.d.2) and 1.J.ii.e.), students are required to attend and participate in all classroom activities. B. Classes and/or clinical experiences may include involvement on any day of the week, weekends, evenings and holidays. C. Students are required to submit an online “Absence Report Form” for all absences. The form can be found in the Moodle “PA Didactic Year Commons”. i. Anticipated absences: a. Students must submit an Absence Report Form at least two business days in advance of the absence. b In addition to the Absence Report Form, students must verbally notify a faculty member at least 24 hours in advance of an anticipated absence. Voice mail messages are not an acceptable form of notification. ii. Unanticipated absences: a. An Absence Report Form must be submitted for an unanticipated absence as soon as is reasonably possible. b. Students must verbally notify a faculty member as close to the time of the unanticipated absence as is reasonably possible. D. Absences in excess of 16 hours per semester or more than 50% of a module are considered excessive and in violation of the Program’s professional behavior standards. The student may be subject to disciplinary action as outlined in Section 1.J.iii. of these General Program Policies and Guidelines. 7. EVALUATION OF STUDENT PERFORMANCE A. Behavioral performance evaluation: i. Student behavioral performance will be evaluated based upon the behavioral objectives and expectations listed in Section 1.J. of this document. B. Course performance evaluation: i. Non-modular courses (Didactic Year fall semester courses) will be evaluated based on criteria established by the faculty member in charge of the course. ii. Module course (Didactic Year spring and summer semester courses) performance evaluation: a. Each student’s performance in a module will be evaluated by the following criteria 1) Objective written examination: A) Minimal passing score: 70% or as outlined on the course syllabus. B) Failure to obtain a minimal passing score: If a student fails to obtain a minimal passing score on the module examination, one (1) repeat examination will be permitted. 23
  • 24. i) The repeat examination will typically be taken within 5 days of the initial examination, but depending on circumstances, the timing may be shortened or lengthened by the faculty. ii) The retake exam may be a repeat of the same exam, a new exam, an essay type exam, a verbal/practical exam, or any variation of the above, as determined by faculty. iii) If the repeat examination is passed, the student will receive a score of 70% for the module examination, even if the score on the repeat examination is higher than 70%. iv) A student may not take more than one makeup examination for the same course. v) Makeup examinations must be taken as scheduled by the PA Program. If a makeup examination is not taken as scheduled, the originally earned grade will prevail. vi) If the student fails the repeat examination the Academic faculty will determine what action will be taken. Available actions include: a) No action b) Remediation c) Referral to the Academic Affairs Committee. Actions of the committee may include: I. Dismissal from the program II. Probation III. Other actions as appropriate to the situation. vii) In the event a student fails more than two written exams in a semester the Academic faculty will determine what action will be taken. Available actions include those previously mentioned in this section. 2) Practical examinations A) Practical examination will be used to evaluate minimal student competence in the following areas: i) Clinical assessment ii) Clinical procedures iii) Other competencies that may be assessed by practical performance or demonstration of a skill B) Practical examinations will be graded on a point system with 70% being the minimal passing standard or a pass – fail system as determined by the faculty member in charge of the course. 24
  • 25. C) Same principles apply to practice as written exams, see 7.B.ii.a.1)B) i) - vii) above 3) Objective exam and practical exams A) The objective exams must be completed at a 70% level or greater (or as stated on the course/module syllabus) and the practical examinations must be completed at a 70% level or greater (or as stated on the course/module syllabus) in order to pass the module. 4) Case presentations A) Case presentations will be evaluated based upon criteria determined by the faculty making the assignment and as listed on the course/module syllabus. 5) Written assignments A) Written assignments will be evaluated based upon criteria determined by the faculty making the assignment and as listed on the course/module syllabus. 6) Grades: All didactic PAS courses will be graded according to the following scale. (This is a recommended scale; an instructor may deviate at his/her discretion; see individual course syllabuses). A 94-100 C 63-65.9 A- 88-93.9 C- 60-62.9 B+ 81-87.9 D+ 57-59.9 B 75-80.9 D 55-56.9 B- 70-74.9 D- 53-54.9 C+ 66-69.9 F 53 and below 8. LEARNING OBJECTIVES A. The most current learning objectives can be found within the syllabus for each module located in the Syllabus Directory of Moodle. http://elearning.isu.edu/moodleisu/mod/book/view.php?id=30036 9. TUTORING A. The didactic year academic load is very heavy and may tax even very well prepared students. Some students may desire tutoring. Academic tutoring can be arranged through the Academic Coordinator. B. In some instances, the PA Program faculty may require a student to obtain tutoring. Tutoring for non PA courses can be arranged through the academic skills office at 282-3662 25
  • 26. 10. DIDACTIC YEAR CLINICAL EXPERIENCES A. Each semester clinical experiences in diverse settings may be arranged by faculty. i. Attendance may be voluntary or may be appointed and required, as deemed appropriate by the faculty. ii. Professional attire is mandatory. Program logo shirts or other professional attire and name badges provided by the program must be worn during these clinical experiences. B. All didactic year clinical experiences require the supervision of at least one Program faculty member. For liability purposes, unassigned (personally arranged) clinical experiences are not covered and are not permitted. 11. ENTRANCE INTO CLINICAL YEAR A. In order to enter the clinical year of the program, each student must meet the following criteria: i. Successfully complete all didactic year classes as outlined in this document a. Achieve an overall cumulative average of 3.0 1) If the cumulative GPA at the end of the didactic phase of the Program is below 3.0 the student may, at the discretion of the AAC, be prohibited from progressing to the clinical year, remediated, or dismissed from the Program b. Have current immunizations, titers, and/or tests as required by ISU and the clinical sites. These include, but are not limited to, MMR, Rubella and Rubeola titers, Tetanus, Hepatitis B immunization, Varicella, Tuberculosis. c. Complete the PACKRAT examination. d. Demonstrate competent physical examination and clinical reasoning skills as determined by clinical skills problems via mock patient, objective examinations, or other simulations, administered by the Program faculty. e. Demonstrate compliance with the PA code of ethics. f. Conform to professional behavior guidelines in this document. g. Read the clinical guidelines and policies section of this handbook, and agree to abide thereby by signing the accompanying statement. B. Background Checks: Clinical sites may require a background check be done by an organization that the site contracts with or may require the student to submit a completed check. Students are responsible for the cost of the background check(s). ISU Public Safety will provide background checks for a fee. 26
  • 27. Capstone Experience 12. CAPSTONE EXPERIENCE Masters Project in PA Studies (PAS 663): The capstone experience will be consistent with the nature of this professional curriculum and will include a comprehensive objective examination, an oral case presentation, and submission of a portfolio. These components have been chosen so that each graduating student has the opportunity to demonstrate competencies in the medical sciences, research, written and oral communication, and the integration of prior learning into evidence-based patient care. A. Comprehensive Examination: A comprehensive written objective examination will be utilized to assure that all students have acquired a minimal level of factual data in the medical sciences. This examination is also designed to help prepare graduating students for the national certification examination that is required for certification in the profession. B. Case Presentation: The case presentation will be an oral, in-depth, critical analysis of the evaluation and care of an actual patient encountered by the student in the clinical year of the program. This oral presentation will require the application of research skills, critical analysis of the literature, evidence-based medicine, as well as depth and breadth of knowledge in primary care medicine. The oral presentation will be given by the student to his/her examining committee. A schedule of deadlines for all materials will be provided at the Fall End of Semester Meeting. i. Advisors & Examining Committees: Examining Committees: The oral presentation committees will consist of three University graduate faculty. One is a designated Graduate Faculty Representative (GFR), who may be chosen by the student, and then recommended by the department to the Graduate School. A list of GFRs is available in the Graduate School catalog. The two remaining committee positions will be occupied be Physician Assistant Program faculty members; one of which will be designated as the committee chair. If the student elects, he/she may have one professional guest attend their oral case presentation. The Dean of Graduate Studies and the student’s committee must approve the guest prior to the oral case presentation. ii. Conflict of Interest of Graduate Faculty: Faculty are expected to exclude themselves from evaluation of graduate students with regard to whom impartiality may be jeopardized by considerations that are not academic. Such considerations may include, but are not limited to, membership in the same household or close familial relationships. iii. Written Report: A brief written report must be handed in to the chair of the student’s examining committee a minimum of two weeks prior to the oral presentation date. The report will be used as a guide for the detailed oral presentation. The report should conform to the American Medical Association’s (AMA) Manual of Style. iv. Oral Defense: The oral defense will consist of an in-depth patient case presentation to the student’s committee and is open to the public. 27
  • 28. a. The student will be examined in detail over all aspects of the case. In order to determine a student’s fund of knowledge, students will be asked questions about the specific aspects of the case presented and will be asked questions about aspects relating to the case. b. Students are free to use supportive materials such as Microsoft PowerPoint, overheads, slides, imaging, etc. during their presentation. 1) Note: Students must request any equipment needed a minimum of two weeks prior to the oral presentation date. Students may not have written materials, PDAs, charts or other aids during the oral examination. C. Portfolio: The portfolio will be developed over the course of the clinical year, and will consist of collections of medical writings authored by the student. This portfolio will allow the faculty to evaluate the student’s ability to communicate complex medical concepts in writing. The student can also use the contents of the portfolio when seeking employment. The portfolio must be professionally bound and include 1 of each of the following: i. Cover page with student name. ii. Table of contents listing each document in the portfolio. iii. Complete Adult History & Physical: a. Identifying Data (excluding patient name) b. Chief Complaint c. History of Present Illness d. Past Medical History e. Family History f. Social History g. Review of System h. Physical Examination i. Laboratory Findings and Diagnostic Studies j. Assessment and Plan iv. SOAP Note: a. Chief Complaint b. Subjective c. Objective d. Assessment and Plan v. Procedure Note: a. Procedure b. Indications c. Permit d. Physicians e. Description of Procedure f. Complications g. EBL (estimated blood loss) h. Specimens/Findings Obtained i. Disposition vi. Inpatient Progress Note: a. Date of Admission b. Admitting Diagnosis 28
  • 29. c. Procedures (with results) to Date d. Hospital Course to Date (briefly summarized) e. Brief Physical Examination (pertinent to patient’s problem) f. Pertinent Lab Data g. Problem List h. Assessment and Plan vii. Inpatient Discharge Summary: a. Date of Admission b. Date of Discharge c. Admitting Diagnosis d. Discharge Diagnosis e. Attending Physician and Service Caring for Patient f. Referring Physician g. Procedures h. Brief History & Physical and Laboratory Data i. Hospital Course j. Condition at Discharge k. Disposition l. Discharge Medications m. Discharge Instructions and Follow-up n. Problem List viii. Psychiatric Note: a. Psychiatric History: 1) chief complaint 2) history of present illness 3) psychiatric history 4) past medical history 5) family history 6) social history 7) developmental psychiatric history 8) review of systems b. Mental Status Examination (MSE): 1) general aspects 2) mood and affect (emotions) 3) speech 4) perception 5) thought 6) cognitive and intellectual functions (Mini-Mental Status Examination [MMSE]) c. Diagnostic Workup d. Assessment and Plan ix. Preoperative Note: a. Preoperative Diagnosis b. Procedure c. Laboratory d. CXR (note results) e. ECG (note results) 29
  • 30. f. Blood g. History and Physical h. Orders i. Permit x. Operative Note: a. Preoperative Diagnosis b. Postoperative Diagnosis c. Procedure d. Surgeons e. Findings f. Anesthesia g. Fluids h. EBL (estimated blood loss) i. Drains j. Specimens k. Complications l. Condition xi. Postoperative Note: a. Procedure b. Level of Consciousness c. Vital Signs d. I&O e. Physical Examination f. Laboratory g. Assessment and Plan xii. Complete Pediatric History & Physical: a. Identifying Data (excluding patient name) b. Chief Complaint c. History of Present Illness d. Past Medical History e. Family History f. Social History g. Review of Systems h. Physical Examination i. Laboratory Findings and Diagnostic Studies j. Assessment and Plan: 1) birth history 2) feeding history 3) growth and development (Denver Development or other scale) 4) immunizations and screening procedures 5) childhood illnesses 6) social development xiii. Delivery Note: A delivery note should follow this format: ___ year old (married or single) G ___ now para ___ AB ___, clinic (note if patient received prenatal clinic care) patient with EDC ___, and a prenatal course (uncomplicated or describe any problems). Any comments concerning 30
  • 31. labor (eg, Pitocin-induced, premature rupture) and draped in the usual sterile fashion. Under controlled conditions delivered a ___ lb ___ oz (___ g) viable male or female infant under ___ (general, spinal, pudendal, none) anesthesia. Delivery was via SVD with midline episiotomy (or forceps or cesarean section). Apgars were ___ at 1 minute and ___ 5 minutes. State delivery date and time. Cord blood sent to lab and placenta expressed intact with trailing membranes. Lacerations of the ___ degree repaired by standard method with good hemostasis and restoration of normal anatomy. a. EBL b. MBT (maternal blood type) c. HCT (predelivery and postdelivery) d. RT (rubella titer) e. VDRL test (venereal disease research laboratory) f. Condition of mother D. Failure of one or more of the components of the Master’s Capstone Project, (End of Clinical Year Exam, Oral Defense of Case Presentation, Portfolio): i. The course instructor will record a grade of IP for the course. ii. The course instructor will notify the student in writing of the areas requiring improvement. iii. The instructor will also submit a Course Completion Contract along with the grade report for the course. The Course Completion Contract must be signed by the student and the instructor stipulating the work and timeline required for completing the course. A copy of the Contract is to be given to the student, a copy retained by the instructor, and the original copy sent to the Registrar’s Office. iv. Only one repeat of the Case Presentation will be allowed. E. Continuing Registration for Graduate Students: i. Graduate students who have registered for one or more credits of master's project, master's paper, master's thesis, or doctoral thesis or dissertation (usually, courses numbered 650, 651, 699, 750, or 850) must be registered for at least one graduate credit during each subsequent semester, including each summer session, until they have completed their degrees ii. Students who for compelling reasons wish to interrupt their work on projects, theses, or dissertations may petition the Graduate School for a leave of absence. iii. Graduate students who fail to meet this continuing registration requirement will be judged to have dropped out of their programs and will no longer enjoy access to university resources, including the library and computer facilities. In order to regain access to university resources, they will be required to reapply to the Graduate School and be readmitted. iv. A corollary of this requirement is that a graduate student must be registered for at least one graduate credit in order to take a final oral examination or be processed for graduation. v. Any student who registers for the required credit and then subsequently drop the credit, will be considered in violation of this policy. 31
  • 32. vi. Incomplete work must be completed within a maximum of (1) calendar year from the date such grade is given. A change of grade form must be submitted by the faculty member or the Incomplete will become permanent. vii. To receive credit for a course in which an Incomplete grade has become a permanent grade, the entire course must be repeated. viii. Petitions to deviate from this policy will not be allowed. 32
  • 33. Introduction to the Clinical Year During the clinical year you will have the opportunity to demonstrate and augment the knowledge and skills which you acquired during the first year of the Physician Assistant Program. You will be assigned to clinical settings which will promote the development of a greater understanding of the health care environment and patient management. The responsibility entrusted to you as a clinical PA student is significant. Therefore, commitment to a high level of professionalism and clinical skill is an integral part of your obligations to the patients, clinical facilities, PA profession and yourself. Maximizing your clinical experience You should be aware that clinical learning experiences and flexibility vary from site to site. • At some sites you may be permitted a full range of participation in patient care activities; • Other sites may impose restrictions relative to chart documentation, certain clinical procedures, administration of medication, on-call, etc. • Restrictions are usually based on institutionally mandated protocols but in some cases preceptors will restrict your activity if they have reservations about your ability or professional conduct. It is your professional obligation to augment clinical experiences with a daily review of the medical literature. By developing a disciplined approach to reading you will build upon your foundation of medical knowledge. This will not only enhance your personal development but will serve as preparation for end of semester written examinations and the national certification examination. Keep in mind that at no other time during your professional career as physician assistants are you likely to be exposed to the variety of medical experiences available to you this year. It is up to you to make the most of this opportunity. 33
  • 34. Clinical Year Policies and Guidelines 13. CLINICAL ROTATION INFORMATION The clinical year consists of 3 semesters of clinical rotations courses and a Master’s project course: a. ISU catalog descriptions: Course Credit Course Titles Description Numbers Hours Clinical 4 Supervised Practicum in medical practice PAS Rotation I, II, credits settings. 660-662 III each Master’s Project An evidence-based medical case study, in Physician completed under the direction of Program PAS 663 2 Assistant faculty. A written report and oral explanation of Studies the case study are required. Graded: S/U Clinical 4 Supervised Practicum in medical practice PAS Rotation IV, V, credits settings. 664-668 VI, VII, VIII each Students will participate in a 2 day meeting. End of 1 Lectures and other content in primary care, PAS Semester credit specialty care, and professional development 669, 670 Meeting I, II each content will be delivered. Cumulative end of semester assignments will be given. b. Clinical Rotations I - VIII Overview: During the clinical year students will complete rotations in: Inpatient Medicine, Outpatient Medicine, Obstetrics & Gynecology, and Pediatrics, Emergency Medicine, Psychiatry, Surgery and an elective area. These focus areas can be completed at one site or multiple sites. c. End of Semester Meetings: Students will return to campus for 2-day meetings at the end of each Fall and Spring semester. d. Rotation change policy: Up until a rotation is confirmed the Clinical Coordinator has the authority to change a rotation. To request a rotation be changed, the student must submit a Rotation Request Form located in Moodle. It is the policy of the Program that once a rotation is confirmed, a student must ask permission of the general faculty in order to change the rotation site or preceptor. e. Out-of-area clinical site policy: i. The Clinical Coordinator will set up the rotation sites for students in Idaho and at established ISU clinical training sites outside of Idaho. ii. If a student desires rotations outside of Idaho or at sites that are not established with the Program, it is the student’s responsibility to make initial contact with the site. The Clinical Coordinator will then facilitate the development and confirmation of that site. iii. The Clinical Coordinator reserves the right to not approve a clinical site if the site doesn’t meet minimum standards or program mission/objectives. 34
  • 35. iv. A student may be given deadlines by the Clinical Coordinator by which site identification must be completed. If a deadline cannot be met, the student must perform the rotation at an affiliated site in Idaho. f. Personally arranged sites: For liability purposes, unassigned (personally arranged) clinical experiences are not covered by student malpractice insurance. g. Preceptorship Policies: Preceptorships are graded educational experiences with potential employment as a possible outcome. 1. It is the Program’s responsibility to provide rotations and preceptorships; however, preceptorships may be arranged by the student or by the Program. 2. Preceptorships may be selected from publicly listed potential employers or potential employers discovered through the efforts of the individual student. 1. Publicly listed employment sites are open to all students on a first come first serve basis. a. The Program will attempt to arrange one preceptorship at a time per student (i.e., multiple simultaneous requests by one student will not be pursued). 2. An employment site developed by an individual student shall be arranged as a preceptorship only for that student. a. The Program will treat this situation as an employment contract negotiation between the individual student and the potential employer, and refrain from interfering in that process beyond qualifying the site and arranging the preceptorship. b. The program will not open or offer the site to any other student without the prior agreement, or the graduation, of the student who developed the site. c. Preceptorship assignment/arrangement issues between student and potential employer must be resolved by those parties. If issues are not resolved by one week prior to the beginning of the preceptorship, the site will not be used and the student will be reassigned. 3. If a student is unable to secure a preceptorship on his/her own by six weeks before the start of the rotation, the Clinical Coordinator will assign the student to a primary care site. 4. Ideally, the student should inform the Clinical Coordinator of an in-state preceptorship site eight weeks prior to the beginning of the preceptorship and should inform the Clinical Coordinator of an out-of-state preceptorship site twelve weeks prior to the beginning of the preceptorship. This will allow adequate time for credentialing of the PA student at the clinical facility and for approval of the legally required Affiliation agreement between ISU and the site. 5. Faculty will not compete for job openings that result from the private efforts of an individual student seeking a preceptorship or employment. h. Rotation selection: Latitude is given to students to select clinical experiences that maximize their interest and needs. Students may choose to do a clinical rotation at one site for an entire semester (15 weeks) or break the rotation up into 10 week or 5 week blocks. Throughout the course of the year students should see diverse patient populations in a variety of clinical settings, therefore seven focus areas have been mandated. The areas are: inpatient, outpatient, pediatric, obstetrics and gynecology, emergency, surgery, and psychiatry. The focus area is 35
  • 36. patient specific, not specialty specific (i.e., students may see an obstetric patient in the family practice setting). 14. TRAVEL FUNDS a. It is the student’s responsibility to pay all travel costs related to Program requirements, including clinical assignments b. Limited travel funds may be available to reimburse students for Program related travel. Availability of travel reimbursement funds is contingent upon grant funding, and cannot be guaranteed. c. Travel Reimbursement/Stipend Policy (Assuming the availability of grant funds): To facilitate students attending rotations in rural and underserved areas funds are available to reimburse travel (to and from clinical sites) and housing. The criteria are: i. Site must be considered one of the following: HPSA, MUAs, MUCs, rural/frontier medical practices, practice serving culturally diverse populations, geriatric practices, or HIV/AIDs clinical training sites. ii. Clinical site must be at least 50 miles from student’s home base. 1. If the above criteria are met, each student may apply for reimbursement. 2. Students may apply for funds by sending an email to the Clinical Year Administrative Assistant. Check with the Administrative Assistant at 208-282-3226 for the current email address. Please include name, social security number, current address for receiving mail, the name and location of the clinical site, and how it meets the above criteria. 3. Reimbursement may be taxable or affect financial aid amounts. 15. CLINICAL YEAR ATTENDANCE a. Clinical Rotation Attendance i. Attendance at clinical rotations is mandatory. If you are unable to report to report to your assigned site for any reason you must: 1. Call your clinical preceptor before your scheduled reporting time. 2. You must call the Physician Assistant Program at (208) 282-4726 by 10:00 a.m. and speak with the Clinical Coordinator or other faculty person. You may not leave a message with non-faculty staff unless you can leave a number where the Clinical Coordinator may reach you. ii. If you are absent from a site and do not call both the preceptor and the PA Program, or if your absence is unexcused or unauthorized, you will be required to make up two days for each day lost. You may also be subject to disciplinary review by the Academic Affairs Committee (AAC). b. End-of-Semester Meeting Attendance i. There will be a mandatory face-to-face meeting at the end of each semester. c. Students are permitted three authorized absences over the entire clinical year. i. An authorized absence is one in which a legitimate and unavoidable cause such as illness or a death in the family prevents the student from attending the rotation or end of semester activities. ii. In cases where there is no authorized absence, the time lost will have to be made up as defined in section XIII. a. ii. 36
  • 37. iii. After three days are missed for any reason, all lost time must be made up. d. On-Call and work schedule policy: i. Students are expected to keep the same clinical hours as their preceptor, up to a maximum of 80 hours per week. ii. Students are expected to be available for call schedule, evenings, weekends (including Sundays), and holidays. iii. Students are expected to be in clinic a minimum of 40 hours per week. iv. In the Emergency Department/urgent care setting students are expected to work a schedule that allows for maximum patient volume and diversity. This schedule should be approved by the preceptor. 16. ACADEMIC STANDARDS a. Grading Criteria: i. Grading criteria for Clinical Rotations I - VIII: Item Grade Patient Log Encounter Objectives 10% Student Evaluation of the site Goal Sheets Preceptor Final Evaluation 50% Extra credit to be added to EOS Exam – Quizzes up to 4 points possible. End of Rotation Exam 40% Total 100% ii. Grading criteria for End of Semester Meeting: Item Grade Attendance and Participation 50% Objective exam over presented 50% material and/or Mock Patient Total 100% iii. Grading scale for the Clinical Year is as follows: A 94-100 C 63-65.9 a. A- 88-93.9 C - 60-62.9 B+ 81-87.9 D+ 57-59.9 B 75-80.9 D 55-56.9 b. B- 70-74.9 D - 53-54.9 C+ 66-69.9 F 53 and below iv. Grading Criteria for Master’s Capstone Project: This course is graded Satisfactory/Unsatisfactory (i.e. no letter grade is given). Successful completion of this course is based on passing the three components: Portfolio, End of Clinical Year (a comprehensive exam) and oral defense of the case presentation. 37
  • 38. b. Good Academic Standing: To successfully complete a clinical rotation and maintain good academic standing you must meet or exceed all of the following criteria: i. Complete and submit Patient Logs, Encounter Objectives, Goal Sheets, and Student Site Evaluations. a. Failure to submit all of the write-ups and the patient logs on the requested date will result in a grade of “I” (incomplete), and a possible loss of 10 percentage points from your final grade. b. The “I” will be removed upon submission of all required write-ups; however, the lost points will not be recovered. ii. An overall grade of 75% must be achieved in each Clinical Rotation course. Additionally, any one component of the clinical grade must not fall below 70% competency. iii. Complete all reading assignments and pass all quizzes. iv. A satisfactory (minimum grade of 70%) preceptor evaluation. a. Failure in this area will necessitate a repeat of the entire rotation, either at the same site or a new site, as determined by the Clinical Coordinator and preceptor. b. The faculty reserves the right to assign the student to an appropriate clinical site. c. End-of-Rotation Exams (EOR): There will be an online objective exam at the end of each rotation. i. Exams will cover the clinical year general objectives for anatomy and physiology, clinical medicine, lab medicine, diagnostic tests, therapeutics. ii. The written EOR examination must be taken as scheduled by the PA Program. iii. Failure to sit for an EOR exam, or to complete the elective presentation may result in a grade of “0" (zero) and a failure in the course. iv. All EOR exams will cover the objectives of the rotation. d. Makeup Examination: i. If you fail to obtain a grade of 70% or better on an end-of-rotation examination, you will be offered the opportunity to remediate the failing grade. 1. If you have failed the examination, you will be allowed to take the test one more time. a. If you receive a grade of 70% or better on the makeup examination/presentation you will receive a maximum score of 70%, provided all other criteria have been met. b. If you fail the makeup examination/presentation, (i.e., receive a grade of less than 70%) you will be required to have remediation and meet all academic performance criteria. c. A student may not take more than one makeup examination for the same course and under no circumstance will a student be permitted to take a makeup examination more than twice in the clinical year. i. Should a student fail the makeup examination, the student must petition the PA Program Academic Affairs Committee (AAC) in order to continue in the Program. (Section I. h.) d. Makeup examinations must be taken as scheduled by the PA Program. If you do not take the makeup examination as scheduled, your originally earned grade will prevail. i. Students should be aware that it is rare that a student fails a clinical rotation because of academic deficiency. In almost all cases students have failed rotations because of failure to observe professional conduct. e. Student Name Tag: a. Your student identification badge is part of your uniform. It is also a state regulation that you wear your name badge identifying yourself as a Physician Assistant student. b. It must be worn at all times and must clearly identify you as a physician assistant student. 38
  • 39. c. Failure to wear proper identification is grounds for immediate dismissal from the clinical site. f. Professional Appearance: The following policies are established to achieve a professional appearance, protect student and patient health, and appeal to the broadest sensitivity of patients’ desires for their health care provider to dress professionally and demonstrate exemplary personal hygiene. i. This is a professional program, and students are required to dress professionally and maintain exemplary personal hygiene. ii. Each preceptor/clinical site will establish the dress code that is appropriate for that site. iii. Unless otherwise specified by the preceptor, professional attire, in the clinical setting, includes a short lab jacket, and for men, a tie. Women’s attire must be consistent with this standard. iv. It is recommended that students, as representatives of ISU and the PA profession, strive to exceed the minimal standard dress code. v. If a student is uncertain regarding appropriate dress/attire it is best to err on the side of conservative professional attire or call the Clinical Coordinator. a. Jeans are not considered professional attire. b. Sneakers/Tennis shoes, sandals and open-toed shoes are not appropriate and expose the student to bodily fluids/excretions. c. Clothing should be clean, well-kept, conservative and tasteful. Clothing should not be tight or sexually revealing (i.e. midriffs and cleavage should be covered, hemlines should be no shorter than four inches above the knee). d. All rings and other jewelry are a nidus for bacteria and other infectious organisms and therefore put patients and clinicians at risk for infection. 1. Rings worn purely for fashion must not be worn during patient care. 2. Rings with raised stones/architecture are additionally problematic because they scratch patients and puncture sterile gloves. 3. Simple bands are acceptable, but require optimal cleanliness. 4. Rings must be removed for procedures requiring sterile technique and some patient handling, and therefore are at risk for being lost or stolen. e. Visible body piercings/decorations during clinical encounters: 1. Minimal ear piercings/decorations (one or two simple studs/ear) are acceptable. 2. Dangling earrings are not appropriate, and constitute a danger because they can easily be grabbed by angry or disoriented patients 3. Tongue piercings/decorations are considered visible, and are not acceptable. 4. Nose piercings/decorations are not acceptable. f. Other jewelry, necklaces, and bracelets worn purely for fashion should be avoided since they harbor infectious agents and can be grabbed and broken by disoriented or hostile patients. g. Medic alert bracelets and necklaces are acceptable h. Students must maintain the highest level of personal hygiene 1. Bathe daily using soap. 2. For patient comfort, avoid offensive body odors as well as strong smelling colognes or perfumes. 3. Hair must be clean and neatly styled. 4. Males must be shaved daily or wear clean, neatly trimmed beards and moustaches. 5. Fingernails: i. Must be short and clean. ii. Long fingernails are a nidus for bacteria and other infectious organisms. iii. Long fingernails preclude adequate performance of physical examination techniques. 39
  • 40. iv. Long fingernails can injure patients. v. Long fingernails can puncture gloves and contaminate sterile fields. vi. Avoid colored nail polish since certain colors can make it difficult to note blood and other body secretions on the nail. vi. The Program faculty will not permit a student to continue in the program if they believe that the student represents a threat to patient welfare or is acting in an unprofessional manner. g. Supervision: i. Appropriate supervision is fundamental to the role of both the student and professional physician assistant. It represents a hallmark of the PA profession and without appropriate supervision the PA cannot legally or ethically provide patient care. ii. The physician assistant student has an obligation to obtain supervision from a person (physician, physician assistant or nurse practitioner) qualified and authorized to provide it. iii. The PA student is assigned to clinical settings in which adequate and appropriate supervision is available. iv. In the event a circumstance arises in which a student is asked or expected to perform clinical procedures or to deliver patient care services without adequate or appropriate supervision, the student must politely but firmly decline and immediately contact the PA Program faculty. v. To protect your personal and professional integrity and to avoid potential legal liability do not perform any patient care activity if: 1. The authorized preceptor or his/her delegate is not on the immediate premises; 2. You have not received adequate instruction and/or are not proficient in or knowledgeable about the care you are asked to deliver and direct supervision is not available; 3. You have reason to believe that such care or procedure may be harmful to the patient; 4. There is no adequate or appropriate supervision available at the time you are expected to carry out the assignment; 5. The care or procedure is self-initiated (i.e., the P.A. student assumes or decides that a particular service or procedure should be performed); or 6. It is beyond the scope of your role as a physician assistant student. vi. In some settings, especially if there are a large number of patients, you may be pressured to perform services which are inappropriate to your level of training or knowledge. It is much easier to defend why you won’t perform a particular task than it is to defend why you endangered a patient’s life. h. Incident Reports: An incident report is a written statement describing the facts and circumstances regarding an occurrence which took place in the course of your assignment. Such an event usually results from error, accident, or negligence and has the potential to cause harm or injury to self, patient, visitor, employee or others. Common examples of “incidents” include: errors in the administration of medication, patients falling out of bed, self-inflicted needle sticks, visitor slipping on a wet floor. i. The student is responsible for completing an incident report regarding any error, accident, or irregular occurrence which takes place while on clinical rotations. ii. Regardless of how minor or insignificant an incident may appear at the time, it is essential that it be reported immediately both verbally and in writing to your supervising preceptor and to the PA Program. iii. Written incident reports serve several functions: 1. A permanent written account of the facts of an event as they have been observed, 2. Are used by risk managers to assess particular existing hazards and to develop measures, if possible, to prevent recurrences, 3. Become part of a statistical accounting of incidents which occur in the institution on an annual basis. 40
  • 41. 4. May serve as an item of evidence in court in the event legal action arises out of a particular incident, 5. Documentation in incident reports prepared by different observers may be important from a risk management or medical-legal point of view. iv. The PA Program faculty will assist you in writing up an appropriate incident report. 17. PROGRESSION FROM CLINICAL YEAR TO GRADUATION a. In order to graduate, each student must meet the following criteria: i. Successfully complete all clinical year classes as outlined in this document ii. Achieve an overall cumulative average of 3.0 a. If the cumulative GPA at the end of the clinical phase of the Program is below 3.0 the student may, at the discretion of the AAC, be prohibited from graduating, be required to complete remediation prior to graduation, or be dismissed from the program iii. Complete the PACKRAT examination. iv. Passing PAS 663 Capstone Experience. (see related section) v. Demonstrate compliance with the PA code of ethics. vi. Conform to professional behavior guidelines in this document. 41
  • 42. 18. INFORMATION FOR PRECEPTORS a. Clinical Rotations i. Purpose of Clinical Rotations: The purpose of the clinical rotations is to enable the student to develop fundamental clinical knowledge and skills under appropriate supervision. The clinical experience gained during the rotation, taken during the second year of the Program, form a crucial part of a PA’s education. During this time the student makes the transition from classroom to clinical practice. Students are required to have a minimum of one clinical rotation in a medically underserved area (e.g. HPSA) and one clinical rotation defined as a Cultural Diverse Group clinical setting. On occasion, one specific clinical location might satisfy both of these requirements. ii. Student Participation: Upon entering the clinical ROTATIONS, the student will have completed one year of the basic and clinical sciences. In addition, the student will have had an introduction to medical practice through a variety of clinical practicums integrated throughout the first 12 months of the PA Program. The history and physical examination is emphasized throughout the first year. iii. Length: The clinical year runs August to August of the following year. Individual rotations vary in length from 1 week to 16 weeks. iv. Liability Insurance: The Physician Assistant student is covered by a liability policy carried by Idaho State University (ISU). A letter stating the policy number and the policy amounts of single and aggregate coverage is provided from the University to the preceptor physician. v. Supervision: ISU will provide the preceptor with rotation objectives. During the initial period, the clinical preceptor should meet with the student to review objectives. The preceptor should become acquainted with the PA student’s capabilities by allowing the student to interact on a one-on-one basis with patients. This interaction is at the discretion of the preceptor and should be based on the perceived level of the student’s experience and expertise. The patient interaction should be utilized as a personalized teaching tool of the preceptor. Students are instructed to respectfully decline in engaging in activities for which they are not prepared. vi. Evaluation: The preceptor is requested to conduct regular evaluations. In so doing, the preceptor should identify areas of weakness to the student that need improvement. The student will then have an opportunity to work on those areas of weakness. The preceptor will be asked to complete a formal end-of-rotation evaluation and assist in the assignment of a rotation grade. Also, students are asked to critique their clinical rotation. A copy of the Evaluation of Student form is included in this handbook or is available to download at the PA Program home page (http://www.isu.edu/paprog). To access the form click on Preceptors, click on Forms, and click on Final Rotation Evaluation Form. vii. CME: Preceptors can receive Category II Continuing Medical Education credit for medical teaching during the preceptorship period. Credits may be claimed for teaching on an hour-for-hour basis. The program will provide documentation of the preceptorship period for CME credit upon request. viii. Affiliate Faculty Status: Interested preceptors will be accorded the title of Affiliate Clinical Faculty to Idaho State University. A certificate will be issued to each preceptor along with privileges granted to affiliate faculty. All interested preceptors must submit a current curriculum vitae/resume with their request to Clinical Coordinator Administrative Assistant, Department of Physician Assistant Studies, 921 S. 8th Ave, 42
  • 43. Stop 8253, Pocatello, ID, 83209. Questions regarding this status should also be directed to the Administrative Assistant at (208) 282-3226. b. Procedure for Establishing and Reviewing Clinical Training Sites i. The physician or clinical site interested in serving as a preceptor contacts the program. In many cases, the program or interested student may contact the prospective site directly. ii. The ISU Clinical Coordinator will speak directly with a representative of the clinical site and determine if the site is suitable for training PA students. The most important criteria for site suitability are a demonstrated willingness to teach and adequate patient encounters. Once suitability is qualitatively determined, the site is approved for students and the appropriate paperwork is initiated. The Clinical Coordinator then schedules an onsite visit at which the Evaluation of Clinical Training Site form is completed. For sites, which are not easily accessible (> 300 miles from the PA program) or unlikely to become active sites in subsequent years, the site visit will be conducted by a phone call to the clinical site. Every active site will be site visited no less than once a year. iii. The Coordinator sends the prospective preceptor a letter of agreement formalizing the preceptorship arrangements. A copy of the Rotation Objectives and other details are sent at this time. iv. Upon receipt of the signed affiliation agreement from the preceptor, the PA Program will complete the signature process and return a signed copy of the agreement letter. With the agreement, the Program will send the preceptor a copy of the malpractice information. v. A confirmation packet is sent to the preceptor two to four weeks before the rotation begins. It contains: a thank you letter with the name and biographical sketch of the assigned student, a folder for all PA Program materials, a Preceptor Handbook including objectives, and a copy of the proof of Malpractice Insurance. The Clinical Coordinator will make a follow-up phone call to the preceptor to confirm that the packet was received and to answer any questions. vi. The PA student will contact the preceptor, one week prior to the beginning of the rotation. During this contact, the student and the preceptor can make arrangements as to the exact time and the place for the beginning of the rotation. vii. The student and preceptor begin by: - reviewing the program objectives - reviewing the preceptor goals - establishing individual student goals. The first meeting should include specific rotational learning objectives and rotational study guide (suggested reading list, conferences to attend, rounds, call schedule, etc.). viii. At mid rotation (weeks 2, 3, and 4 of the rotation), the Clinical Coordinator will contact each preceptor or site representative and conduct a mid rotation evaluation of the student. This mid rotation evaluation may be done in person, by phone call, or by fax or email. The site will be visited no less than once a year by the clinical coordinator, and more frequently if need arises. ix. Should there be ANY questions and or problems, please contact the clinical coordinator or the PA Program at (208) 282-4726. 43
  • 44. c. Preceptor / PA Student Scope of Practice i. Here are some guidelines regarding what a PA student may be permitted to do by the preceptor. Please note that these are guidelines only. The judgment of the preceptor regarding how much responsibility a student is ready for should determine what tasks are delegated and how much supervision is provided. In most clinical settings the PA student sees patients together with the preceptor during the first part of the preceptorship. As skills develop, the student progresses to seeing the patient alone, discussing the problem with the provider; and then the student and preceptor seeing the patient together. This is usually a rapid progression during the course of the rotation due to the short length of the clinical rotations. It is highly encouraged that the student's level of responsibility be allowed to progress as quickly as their expertise develops. In Idaho, PA students may perform medical services when rendered within the scope of an approved PA Program and under supervision by a licensed provider. PA students tend to be quick and motivated learners. Preceptors report that teaching techniques, which are successful with medical students, also work well with PA students. Some have not had technical exposure but other factors will make them good candidates for the PA profession. Typical tasks assigned to PA students by preceptors include: 1 Taking histories and doing physical examinations 2. Assessing common medical problems and recommending management 3. Performing and assisting in routine lab and therapeutic procedures 4. Counseling patients about health care 5. Assisting the provider in the hospital and making rounds, recording progress notes, transcribing specific orders of the supervising Preceptor as allowed by the hospital by-laws 6. Evaluation and management of emergencies until the preceptor arrives 7. Following protocols or standing orders of the preceptor. d. Responsibilities During Clinical Rotation i. Purpose of the Rotation: To provide second year PA students with opportunities to develop basic clinical skills and knowledge under the supervision of licensed practitioners. ii. Description: During the 12 months of the clinical year, PA students rotate though a cross section of clinical specialties including: a minimum of four weeks in each setting of Outpatient Medicine, Inpatient Medicine, Surgery, Emergency Medicine, Obstetrics/Gynecology, Pediatrics, Psychiatry, and electives. While on these rotations the student learns the fundamentals of PA practice under the supervision and direction of the supervising preceptor. iii. Student Responsibilities: 1. Arrange own transportation, room and board; 2. Devote full-time effort to the clinical rotation; 3. Conduct themselves in a professional manner at all times; 4. Complete the rotation objectives and directed readings; 5. Complete history and physical write-ups as outlined in each rotation's objectives and turn in to the Clinical Coordinator. 44
  • 45. iv. Preceptor Responsibilities: 1. Be a licensed, practicing provider in good standing with their regulatory board. 2. Provide credentialing information as requested. 3. Provide students with medical opportunities to learn both the art and science of medicine. 4. The precepting provider is requested to undertake an early, mid, and end rotational conferences with the student. The purpose of this conference is to note the student's strengths, accomplishments and weaknesses that have been demonstrated during the rotation. A brief narrative summary of this conference should accompany the evaluation, which is completed at the end of the rotation. 5. Evaluate the student's performance at the end of the clinical preceptorship on the form provided in the handbook or from (http://www.isu.edu/paprog). To access the form click on Preceptors, click on Forms, and click on Final Rotation Evaluation Form. 6. Ensure that the student is appropriately supervised. 7. Assign the student patients and review all information before the patient is finished. 8. Administrative responsibility to introduce the student to the office personnel, other health care providers, and hospital community personnel. The preceptor should clearly define the students work hours and work dress code as outlined in the clinical year handbook. Any problems between the student and the preceptor will be reported to the ISU Clinical Coordinator. 9. The PA student should never be utilized as a substitute for an ill or otherwise absent employee. v. Program Responsibilities 1. Provide the preceptor with a letter documenting the teaching experience for Category II CME credit (if requested by the preceptor). 2. Issue the preceptor a certificate of Affiliate Clinical Faculty, when University qualifications are met. Nominations are made to the President of ISU twice a year (August and November). 3. Coordinate student preceptorships and maintain education records. 4. Maintain PA Program accreditation. 5. Provide malpractice insurance for the student. 6. Prepare the student didactically for the clinical rotations. Upon completion of the rotation, the student will be able to use the problem oriented approach to elicit a medical history, perform a pertinent physical examination, obtain indicated laboratory studies, assess the results, formulate a management plan, transmit information, and assist in the implementation of appropriate therapy for the common problems encountered in the rotation. As a member of the health care team, the student will develop an understanding of the PA role in this setting. The student will develop the attitudes and communication skills necessary to establish effective interpersonal relationships with patients and health care professionals. 45
  • 46. vi. Evaluation 1. Subjective Data - Medical History: The student should be able to obtain information sufficient to conceptualize a medical problem, demonstrating ability to: a. Use the problem-oriented approach to gather subjective information. b. Collect comprehensive data pertinent to the patient’s problems from the following areas: A. Chief Complaint B. Present Illness C. Past medical history D. Family medical history E. Personal/social history F. Review of systems G. Previous medical records H. Patient profile (background) c. Use effective interview methods d. Emphasize: i. Systematic organization ii.. Follow-up of clues iii. Evaluation of historical facts vii. Objective Data 1. Physical Examination: The student should be able to: a. Use effective and systematic examining techniques the results of which are reproducible by other clinicians. b. Emphasize examination of organ systems identified as problem areas by history c. Perform a comprehensive physical examination when indicated d. Identify normal/abnormal physical findings through observation and practice. e. Use the physical findings to support or modify tentative diagnostic impressions developed in the history 2. Laboratory: The student should be able to: a. Order indicated tests b. Obtain technically valid specimens c. Perform office laboratory procedures d. Evaluate results of diagnostic tests to support or modify the tentative diagnostic impressions 3. Assessment: The student should be able to analyze information obtained from the history, physical examination, laboratory tests, and procedures to: a. List the patient’s problems b. Formulate a differential diagnosis 4. Plan/management: a. Become familiar with the appropriate management of medical emergencies prior to the arrival of the physician. b. Recognize indications for physician consultation. c. Formulate and assist in implementation of a management plan including: A. Patient education and counseling procedures B. Medical therapies, procedures, treatment and referral 46
  • 47. C. Follow-up care D. Develop skills necessary to perform or assist in the performance of common diagnostic and therapeutic procedures. E. Become knowledgeable of community resources and refer to the appropriate agency when indicated. F. Record clinical information according to the problem-oriented medical record system using these categories: subjective, objective, assessment, and plan (SOAP Method). viii. Physician Assistant Role: 1. Recognize the role of the physician assistant and its dependence on effective interpersonal relations with patients and professionals: a. Attain interpersonal skills that facilitate the patient’s understanding of a problem and participation in its management. b. Demonstrate concern for the patient by maintaining professional attitude and by respecting the patient’s privacy. c. Develop understanding of the capabilities and limitations of a PA. 2. Develop effective methods of organizing new medical information for each retrieval. 3. Maintain competency through continuing medical education. ix. Common Clinical Problems: For the common problems in any clinical setting, the student should be able to describe: 1. Signs and symptoms 2. Cause and natural history 3. Diagnostic laboratory tests 4. Appropriate management, including indications for physician consultation and referral 19. CLINICAL YEAR OBJECTIVES The objectives are in 3 main parts which include the Program Outcome Objectives, the General Clinical Year Objectives, and the Specific Clinical Rotation Objectives. 47
  • 48. Part I PA Program Outcome Objectives Graduates of the ISU PA Program will, using appropriate evidence-based principles, achieve the following objectives: 1. History: Elicit an appropriate complete, interval or acute history from any patient in any setting. 2. Physical Examination: Perform a complete and focused physical examination on a patient of any age, gender, or condition in any setting. 3. Diagnostic Studies: Identify, order, perform and interpret, cost-effective, diagnostic procedures, based on history and physical examination findings, and assist the physician with other diagnostic procedures as directed. 4. Clinical Knowledge: Explain the etiology, diagnosis, and management options of health problems within the scope of PA practice. 5. Differential Diagnosis: Develop an evidence-based differential diagnosis and diagnostic impression considering the subjective and objective data obtained. 6. Therapeutics: Identify, perform, and order cost effective pharmacologic and non- pharmacologic therapeutic modalities and assist the physician with other therapeutic modalities. 7. Health Promotion/Disease Prevention: Recognize, develop and implement effective strategies for incorporating health promotion/disease prevention into clinical practice. 8. Emergency Skills: Recognize and manage life-threatening conditions jointly with, and in the absence of, the physician. 9. Communication/Patient Education: Be able to collaborate and effectively communicate in a medically professional manner, both orally and in writing, to the patient, the family, and with other health professionals. 10. Research: Apply evidence-based medical research methodologies to clinical practice. 11. Cultural Competence: Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 12. Ethics: Act consistently with the American Academy of Physician Assistant’s (AAPA) Code of Ethics of the PA Profession as presented in Appendix A. 48
  • 49. Part II General Clinical Year Objectives While emphasizing the health care needs of rural populations, the following general objectives will be achieved: 1. HISTORY: Elicit an appropriate complete, interval or acute history from patients of any age, gender or condition in any setting. A. Obtain a clear, concise chief complaint and history of the present illness. B. Obtain a complete past medical history including illnesses, hospitalizations, surgeries, trauma and childhood illnesses. C. Obtain a history of allergies, transfusion reactions, and reactions to medications. D. Obtain a pertinent social history including occupation, current life situation, nutrition, uses of tobacco, alcohol and other drugs. E. Obtain a list of current medications along with details as to use, dose and schedules, including the use of over-the-counter medications. F. Obtain a family history pertaining to exposure to illness, familial predisposition to disease, or genetic transmission. G. Obtain a pertinent review of body systems. H. Obtain an interval history pertaining to progression, regression or stability of chronic illness. I. Obtain a brief outpatient history pertaining to an acute illness. J. Record all pertinent historical data on the defined database in a clear, concise and relevant manner. 2. PHYSICAL EXAMINATION: Perform a complete and focused physical examination on a patient of any age, gender, or condition in any setting. A. Demonstrate ability to gain the patient’s confidence and provide reassurance about the examination. B. Demonstrate appropriate use of the instruments used for the physical examination. C. Perform a complete, logical and sequential physical examination. D. Demonstrate the ability to alter the sequence and content of the examination according to the special need of the individual patient. E. Perform an appropriate limited examination pertaining to progression, regression or stability of chronic illness. F. Perform an appropriate physical examination on an acute illness. G. Recognize the physical examination findings that are normal and abnormal for the patient’s age and gender. H. Record all normal and abnormal findings on the defined database. 3. DIAGNOSTIC STUDIES: Identify, order, perform and interpret, cost-effective, diagnostic procedures, based on a history and physical examination findings, and assist the physician with other diagnostic procedures as directed. A. Identify the appropriate and available diagnostic tests for a particular problem based on the history and physical examination findings. B. Identify and discuss indications and contraindications of the various diagnostic tests. 49
  • 50. C. Identify and describe the risks, costs and patient inconvenience of various diagnostic tests. D. Demonstrate skills required to collect routine specimens. 1. bacteriologic samples 2. blood, venous and arterial 3. gastric contents 4. sputum 5. stool 6. tissues 7. urine E. Demonstrate skills necessary to perform and/or interpret basic laboratory tests. 1. CBC 2. gram stain 3. stool, O&P 4. stool, guaiac 5. urinalysis, dipstick 6. wet prep/KOH 7. pregnancy test 8. alcohol screening F. Demonstrate skills necessary to perform and interpret a 12 lead EKG and rhythm strip. G. Administer, interpret and record results of intradermal skin test. H. Demonstrate skills necessary to perform and interpret screening tonometry and audiometry tests. I. Identify, order and/or perform and/or interpret other selected diagnostic tests. J. Order and make preliminary assessment of routine radiologic studies, including PA and lateral chests, KUB, GI, GB and extremity films. K. Know routine preparation for common X-ray studies. L. Be familiar with techniques of anoscopy, proctoscopy, sigmoidoscopy, bronchoscopy, gastroscopy, endoscopy and colonoscopy. M. Be familiar with techniques of thoracentesis, paracentesis, arthrocentesis, pericardiocentesis and lumbar puncture. N. Be familiar with routine nuclear medicine studies/reports. O. Be familiar with the technique of excisional biopsy. P. Recognize the signs and symptoms of complications of diagnostic procedures performed or ordered. 4. CLINICAL KNOWLEDGE: Explain the etiology, diagnosis, and management options of health problems within the scope of PA practice. A. Explain the etiology and pathophysiology of common primary care health problems. B. List the diagnostic criteria of common primary care health problems. C. Describe the management options for common primary care health problem. 5. DIFFERENTIAL DIAGNOSIS: Develop a differential diagnosis and diagnostic impression considering the database. A. Develop a differential diagnosis and diagnostic impression at each stage of data collection. B. Demonstrate ability to organize and integrate data from the medical history, physical examination and diagnostic studies. 50
  • 51. C. Demonstrate sound medical judgment in formulating a differential diagnosis and reaching a diagnostic impression. D. Be familiar with the common medical problems seen in rural primary care and their modes of presentation. 6. THERAPEUTICS: Identify, perform, and order cost effective pharmacologic and non- pharmacologic therapeutic modalities and assist the physician with other therapeutic modalities. A. Administer intravenous infusions utilizing appropriate equipment including scalp vein needle, butterfly needle, intravenous catheter, heparin lock and infusion pumps. B. Calculate infusion rate. C. Administer injections by a variety of routes including intradermal, subcutaneous, intramuscular and intravenous. D. Be familiar with normal nutritional requirements. E. Be familiar with dietary treatment of health problems including weight reduction, diabetic, low fat, low cholesterol and low sodium diets. F. Be familiar with the drugs used most frequently in treatment of health problems including basic modes of action, indications, contraindications and complications. G. Be familiar with the management of common medical problems. 7. HEALTH PROMOTION/DISEASE PREVENTION: Recognize, develop and implement effective strategies for incorporating health promotion/disease prevention into clinical practice. A. Know the appropriate, recommended health screening services for each gender through the lifespan. B. Know the risk factors for preventable diseases. C. Know the personal health behaviors that can predispose to illness. D. Know the recommended immunizations for each gender throughout the lifespan. E. Know the various chemoprophylactic regimens that can be offered to patients before they develop clinical evidence of disease. F. Instruct the female patient in self-breast examination technique and its importance. G. Recognize the importance of patient education in effecting change in the health status of both individuals and groups. 8. EMERGENCY SKILLS: Be able to recognize and manage life-threatening emergencies jointly with, and in the absence of, the physician. A. Recognize signs and symptoms of common emergencies and take appropriate action to sustain life. B. Apply basic techniques of CPR. 1. establish an airway 2. initiate or sustain effective ventilation 3. perform external cardiac massage C. Assist with or perform other techniques frequently indicated in life-threatening situations. 1. endotracheal/nasogastric intubation 2. cricothyrotomy 3. defibrillation/cardioversion 4. central line insertion 51
  • 52. 5. central venous pressure monitoring D. Initiate hemostasis in patients with hemorrhage. E. Assess and treat hemorrhagic shock. F. Support and treat patients with anaphylactic reaction. G. Communicate with the physician regarding the patient’s emergency status as soon as possible. H. Administer and/or advise regarding the first aid indicated in the overdose, accidental ingestion or attempted suicide with drugs and other chemical agents. I. Know the reference sources regarding toxic materials. J. Recognize potentially lethal cardiac dysrhythmias and know the current treatment for each. K. Recognize altered mental status and its common causes and treatment. L. Understand the use of and indications for standard emergency medications and administer if appropriate. M. Be familiar with triage procedures in mass casualty situations. N. Respect the decision of the patient and/or family for no advanced life support procedures. O. Assess patients with multiple trauma, skull and/or spinal injuries. 9. COMMUNICATION/PATIENT EDUCATION: Be able to communicate in a medically professional manner, both orally and in writing, to the patient, the family and with health care professionals. A. Present to the physician a brief synopsis of the patient’s present illness, pertinent positive and negative findings and the diagnostic and therapeutic regimen instituted. B. Communicate effectively with both patient and family by using a vocabulary familiar to all concerned. C. Counsel patient and family regarding the health problem including an explanation of the disease process, therapy and its rationale, therapeutic options, prognosis and health care services available. D. Develop and implement effective patient education strategies for any patient in any setting. E. Write routine and all other orders that are appropriate to the problem. F. Write in a SOAP format, clear concise and relevant progress notes including diagnostic, therapeutic and patient education plans. A. Fill out routine laboratory test and diagnostic procedure request forms accurately and with pertinent data. B. Maintain a complete up-to-date problem list. C. Initiate requests for patient services including public health and home nursing, school testing and evaluation and release of medical records. D. Report communicable diseases utilizing appropriate forms and follow-up. E. Write interval notes. F. Perform discharge summaries. G. Give empathetic support to both patient and family in all communications. 52
  • 53. 10. RESEARCH: Apply evidence-based medical research methodologies to clinical practice. A. Perform appropriate and effective medical literature searches utilizing current means including electronic databases and search engines. B. Recognize, describe and critique common research designs utilized in medical research. C. Utilize and explain statistical concepts commonly encountered in the medical literature, including sensitivity, specificity, and predictive values. D. Interpret and critique meta-analyses of the medical research literature. 11. CULTURAL COMPETENCE: Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. A. Increase understanding of the major cultural diverse groups in Idaho; B. Increase self-awareness of the attributes of one’s own individual cultures; C. Identify how an individual’s culture affects an individual’s interpersonal skills; 12. ETHICS: Act consistently with the AAPA’s Code of Ethics of the PA Profession (see Appendix A). 53
  • 54. Part III: Specific Clinical Rotation Objectives Primary Care Rotations The following are the objectives for the main focus areas in the Primary Care Medicine Clinical Rotation. They cover the focus areas of Inpatient and Outpatient medicine, Obstetrics and Gynecology, and Pediatrics. Primary Care Rotation: Outpatient and Inpatient These focus areas may be completed in conjunction with other primary care focus areas at a family practice site or as separate, shorter individual rotations in Outpatient and Inpatient Medicine. In addition to the Outcome Objectives and the General Clinical Year Objectives previously listed, the student will be responsible for the following Outpatient and Inpatient objectives: HISTORY 1. Be able to elicit an appropriate history from a patient in the office, or inpatient setting. a. Elicit detailed history regarding dietary habits, sleep patterns behavior changes use of medications (prescription or OTC), drugs or alcohol. b. Elicit history of hearing or visual disturbances c. Elicit information regarding patient’s home environment, support network and financial status. d. Elicit a careful comprehensive history through several interview sessions. e. Appropriately utilize a second party to augment information obtained from a patient. f. Be aware that the process of aging alters both the historical and physical manifestations of certain diseases. g. Be aware that geriatric patients may underreport illness. PHYSICAL EXAMINATION 1. Perform a physical examination on a patient in the office, or inpatient setting allowing for: a. Variations in physical findings among the different aged population. b. Common normal physical findings c. Abnormal physical findings that are found with increased frequency in this the geriatric population. DIAGNOSTIC STUDIES 1. Identify, perform, order and/or interpret appropriate, cost-effective, routine diagnostic procedures, based on history and physical examination findings, and be able to assist the physician with other diagnostic procedures as directed. a. Identify the appropriate and available diagnostic tests for a particular problem based on the history and physical examination findings. b. Identify and discuss indications and contraindications of the various diagnostic tests. c. Identify and describe the risks, costs and patient inconvenience of various diagnostic tests. d. Demonstrate skills required to collect routine specimens. 54
  • 55. 1. bacteriologic samples 2. blood, venous and arterial 3. gastric contents 4. sputum 5. stool 6. tissues 7. urine e. Demonstrate skills necessary to perform and/or interpret basic laboratory tests. 1. CBC 2. gram stain 3. stool, O&P 4. stool, guaiac 5. urinalysis, dipstick 6. wet prep/KOH 7. pregnancy test 8. alcohol screening f. Demonstrate skills necessary to perform and interpret a 12 lead EKG and rhythm strip. g. Administer, interpret and record results of intradermal skin test. h. Demonstrate skills necessary to perform and interpret screening tonometry and audiometry tests. i. Identify, order and/or perform and/or interpret other selected diagnostic tests. j. Order and make preliminary assessment of routine radiologic studies, including PA and lateral chests, KUB, GI, GB and extremity films. k. Know routine preparation for common X-ray studies. l. Be familiar with techniques of anoscopy, proctoscopy, sigmoidoscopy, bronchoscopy, gastroscopy and endoscopy and colonoscopy. m. Be familiar with techniques of thoracentesis, paracentesis, arthrocentesis, pericardiocentesis and lumbar puncture. n. Be familiar with routine nuclear medicine studies/reports. o. Be familiar with the technique of excisional biopsy. p. Recognize the signs and symptoms of complications of diagnostic procedures performed or ordered. CLINICAL KNOWLEDGE: Explain the etiology, diagnosis, and management options of health problems within the scope of PA practice. a. Explain the etiology and pathophysiology of common primary care health problems. b. List the diagnostic criteria of common primary care health problems. c. Describe the management options for common primary care health problem. DIFFERENTIAL DIAGNOSIS 1. Develop a differential diagnosis and diagnostic impression considering the data base a. Develop a differential diagnosis and diagnostic impression at each stage of data collection. b. Demonstrate the ability to organize and integrate data from the medical history, physical examination, and diagnostic studies. c. Demonstrate sound medical judgment in formulating a differential diagnosis. d. Demonstrate skills necessary to accurately record and present data in a manner appropriate to the setting. 55
  • 56. e. Be familiar with the common medical problems and their modes of presentation, including: Cardiovascular System Cardiac risk Factors Cardiogenic shock Coronary artery Disease Orthostasis/postural Pericarditis Ischemic Heart Disease: Congestive heart failure Acute myocardial infarction Aneurysm/Occlusion Angina pectoris Valvular heart disease -Stable Endocarditis -Unstable Hypertension -Prinzmetal’s/variant Cardiac rehabilitation Vascular Disease Cardiomyopathy Acute rheumatic fever Dilated Aortic aneurysm/dissection Hypertrophic Arterial embolism/thrombosis Restrictive Chronic/acute arterial occlusion Conduction Disorders: Giant cell arteritis Atrial fibrillation/flutter Peripheral vascular disease Atrioventricular block Phlebitis/thrombophlebitis Bundle branch block Venous thrombosis Paroxysmal supraventricular tachycardia Varicose veins Premature beats Other forms of Heart Disease: Ventricular Tachycardia Cardiac tamponade Ventricular fibrillation/flutter Pericardial effusion Hypotension: Pulmonary System Pulmonary function testing/Arterial • Bacterial blood gases • Viral Inhalational and Environmental Injury • Fungal Silo-Fillers Disease (Hypersensitivity • HIV-related Pneumonitis) Respiratory syncytial virus infection Farmer’s Lung Tuberculosis Black Lung-Coalworker’s Neoplastic Disease Pneumoconiosis Bronchogenic carcinoma Tobacco abuse/cessation Carcinoid tumors Pulmonary Edema/Hypertension Metastatic tumors Infectious Disorders Pulmonary nodules Acute bronchitis Obstructive Pulmonary Disease Acute bronchiolitis Asthma Acute epiglottitis Bronchiectasis Croup Chronic bronchitis Influenza Cystic fibrosis Pertussis Emphysema Pneumonias Pleural Diseases Pneumothorax Pleural effusion • Primary 56
  • 57. • Secondary Pneumoconiosis • Traumatic Sarcoidosis • Tension Other Pulmonary Disease Pulmonary Circulation Acute respiratory distress syndrome Pulmonary embolism Hyaline membrane disease Pulmonary hypertension Foreign body aspiration Cor pulmonale Restrictive Pulmonary Disease Idiopathic pulmonary fibrosis Nephrology/Urology Urinary tract infections Neoplastic Diseases Dialysis Bladder carcinoma Sexually transmitted diseases Prostate carcinoma Nephrotoxins Renal cell carcinoma Benign Conditions of the GU Tract Testicular carcinoma Benign prostatic hyperplasia Wilms' tumor Cryptorchidism Renal Diseases Erectile dysfunction Acute/chronic renal failure Hydrocele/varicocele Glomerulonephritis Incontinence Nephrotic syndrome Nephro/urolithiasis Polycystic kidney disease Paraphimosis/phimosis Electrolyte and Acid/Base Disorders Testicular torsion Hypo/hypernatremia Infectious/Inflammatory Conditions Hypo/hyperkalemia Cystitis Hypo/hypercalcemia Epididymitis Hypomagnesemia Orchitis Metabolic alkalosis/acidosis Prostatitis Respiratory alkalosis/acidosis Pyelonephritis Volume depletion Urethritis Volume excess Neurologic System Seizure disorder Headaches Multiple Sclerosis Cluster headache Neuropathies: Cranial/Peripheral Migraine Spinal disc disease Tension headache Coma/CNS trauma Infectious Disorders Alzheimer's Disease Encephalitis Cerebral Palsy Meningitis Diseases of Peripheral Nerves Movement Disorders Bell's palsy Essential tremor Diabetic peripheral neuropathy Huntington's disease Guillain-Barre syndrome Parkinson's disease Myasthenia gravis 57
  • 58. Vascular Diseases Cerebral aneurysm Stroke Transient ischemic attack Gastrointestinal System/Nutrition Dysmotility Inflammatory bowel disease Malabsorption Intussusception Jaundice Irritable bowel syndrome Cholangitis Ischemic bowel disease Diarrhea/Constipation Neoplasms Hemorrhoids/Fissures/Fistulas Obstruction Infections: Viral, Bacterial, Parasitic Toxic megacolon Esophagus Rectum Esophagitis Anal fissure Motor disorders Anorectal abscess/fistula Mallory-Weiss tear Fecal impaction Neoplasms Hemorrhoids Strictures Neoplasms Varices Pilonidal disease Stomach Polyps Gastroesophageal reflux disease Hernia Gastritis Hiatal Neoplasms Incisional Peptic ulcer disease Inguinal Pyloric stenosis Umbilical Gallbladder Ventral Acute/chronic cholecystitis Infectious Diarrhea Cholelithiasis Nutritional Deficiencies Liver Niacin Acute/chronic hepatitis Thiamine Cirrhosis Vitamin A Neoplasms Riboflavin Pancreas Vitamin C Acute/chronic pancreatitis Vitamin D Neoplasms Vitamin K Small Intestine/Colon Metabolic Disorders Appendicitis Lactose intolerance Constipation Phenylketonuria Diverticular disease Rheumatology Osteoarthritis Collagen Vascular Disease Rheumatoid Arthritis Fibromyalgia Infectious Arthritis: Gout/pseudogout Viral/Bacterial/Lyme Polyarteritis nodosa 58
  • 59. Polymyositis Rheumatoid arthritis Polymyalgia rheumatica Systemic lupus erythematosus Reiter's syndrome Scleroderma Sjogren's syndrome Endocrine System Diseases of the Thyroid Gland Diseases of the Pituitary Gland Hyperparathyroidism Acromegaly/gigantism Hypoparathyroidism Dwarfism Hyperthyroidism Diabetes insipidus • Graves' disease Diabetes Mellitus • Hashimoto's thyroiditis Type 1 • Thyroid storm Type 2 Hypothyroidism Hypoglycemia Thyroiditis Lipid Disorders Neoplastic disease Hypercholesterolemia Diseases of the Adrenal Glands Hypertriglyceridemia Cushing's syndrome Corticoadrenal insufficiency Dermatologic System Dermatologic Manifestations of Toxic epidermal necrolysis Systemic Erythema multiforme Disease Vesicular Bullae Eczematous Eruptions Bullous pemphigoid Dermatitis Acneiform Lesions • Atopic Acne vulgaris • Contact Rosacea • Diaper Folliculitis • Nummular eczematous Verrucous Lesions • Perioral Seborrheic keratosis • Seborrheic Actinic keratosis • Stasis Insects/Parasites Dyshidrosis Lice Lichen simplex chronicus Scabies Papulosquamous Diseases Spider bites Dermatophyte infections Neoplasms • Tinea versicolor Basal cell carcinoma • Tinea corporis/pedis Melanoma Drug eruptions Squamous cell carcinoma Lichen planus Hair and Nails Pityriasis rosea Alopecia areata Psoriasis Androgenetic alopecia Desquamation Onycomycosis Stevens-Johnson syndrome Paronychia 59
  • 60. Viral Diseases Other Condyloma acuminatum Acanthosis nigricans Exanthems Burns Herpes simplex Decubitus ulcers/leg ulcers Molluscum contagiosum Hidradenitis suppurativa Verrucae Lipomas/epithelial inclusion cysts Varicella-zoster virus infections Melasma Bacterial Infections Urticaria Cellulitis/vasculitis Vitiligo Erysipelas Impetigo Hematologic System Immune Deficiencies Factor IX disorders Anemias Factor XI disorders Aplastic anemia Thrombocytopenia Vitamin B12 deficiency • Idiopathic thrombocytopenic purpura Folate deficiency • Thrombotic thrombocytopenic purpura Iron deficiency • Von Willebrand's disease G6PD deficiency Malignancies Hemolytic anemia Acute/chronic lymphocytic leukemia Sickle cell anemia Acute/chronic myelogenous leukemia Thalassemia Lymphoma Coagulation Disorders Multiple myeloma Factor VIII disorders Allergy/Immunology Anaphylaxis Hypersensitivity Eyes, Ears, Nose & Throat Eye Disorders Hordeolum Blepharitis Hyphema Blowout fracture Macular degeneration Cataract Orbital cellulitis Chalazion Pterygium Conjunctivitis Retinal detachment Corneal abrasion Retinal vascular occlusion Dacryoadenitis Retinopathy Ectropion • Diabetic Entropion • Hypertensive Foreign body Strabismus Glaucoma 60
  • 61. Ear Disorders Epistaxis Acute/chronic otitis media Nasal polyps Barotrauma Mouth/Throat Disorders Cerumen impaction Acute pharyngitis Hearing impairment Acute tonsillitis Mastoiditis Aphthous ulcers Meniere's disease Dental abscess Labyrinthitis Epiglottitis Otitis externa Laryngitis Tympanic membrane perforation Oral candidiasis Vertigo Oral herpes simplex Nose/Sinus Disorders Oral leukoplakia Acute/chronic sinusitis Peritonsillar abscess Allergic rhinitis Parotitis Sialadenitis Mental Health Psychiatric emergencies Avoidant Sleep disorders Borderline Personality disorders Histrionic Dementia Narcissistic Substance abuse and dependence Obsessive-compulsive Anxiety Disorders Paranoid Panic disorder Schizoid Generalized anxiety disorder Schizotypal Posttraumatic stress disorder Psychoses Phobias Delusional disorder Attention-Deficit Disorder Schizophrenia Autistic Disorder Schizoaffective disorder Eating Disorders Somatoform Disorders Anorexia nervosa Substance Use Disorders Bulimia nervosa Alcohol abuse/dependence Obesity Drug abuse/dependence Mood Disorders Tobacco use/dependence Adjustment Other Behavior/Emotional Disorders Depressive Acute reaction to stress Dysthymic Child/elder abuse Bipolar Domestic violence Personality Disorders Uncomplicated bereavement Antisocial 61
  • 62. Musculoskeletal System Disorders of the Shoulder Low back pain Fractures/dislocations Spinal stenosis Rotator cuff disorders Disorders of the Hip Separations Aseptic necrosis Sprain/strain Fractures/dislocations Disorders of the Forearm/Wrist/Hand Slipped capital femoral epiphysis Fractures/dislocations Disorders of the Knee • Boxer's Bursitis • Colles' Fractures/dislocations • Gamekeeper's thumb Meniscal injuries • Humeral Osgood-Schlatter disease • Nursemaid's elbow Sprains/strains • Scaphoid Disorders of the Ankle/Foot Sprains/strains Fractures/dislocations Tenosynovitis Sprains/strains • Carpal tunnel syndrome Infectious Diseases • de Quervain's tenosynovitis Acute/chronic osteomyelitis • Elbow tendinitis Septic arthritis • Epicondylitis Neoplastic Disease Disorders of Back/Spine Bone cysts/tumors Ankylosing spondylitis Ganglion cysts Back strain/sprain Osteosarcoma Cauda equina Osteoarthritis Herniated nucleus pulposis Osteoporosis Kyphosis/scoliosis Infectious Diseases Fungal Disease Chlamydia Candidiasis Cholera Cryptococcosis Diphtheria Histoplasmosis Gonococcal infections Pneumocystis Salmonellosis Bacterial Disease Shigellosis Botulism Tetanus Mycobacterial Disease Spirochetal Disease Tuberculosis Lyme borreliosis Atypical mycobacterial disease • Lyme disease Parasitic Disease Rocky Mountain spotted fever Amebiasis Syphilis Hookworms Viral Disease Malaria Cytomegalovirus infections Pinworms Epstein-Barr virus infections Toxoplasmosis Erythema infectiosum Herpes simplex 62
  • 63. HIV infection Roseola Human papillomavirus infections Rubella Influenza Measles Mumps Varicella-zoster virus infections Rabies THERAPEUTICS 1. Identify, perform, and order cost effective pharmacologic and non-pharmacologic therapeutic modalities and assist the physician with other therapeutic modalities. a. Administer intravenous infusions utilizing appropriate equipment including butterfly needle, intravenous catheter, heparin lock and infusion pumps. b. Calculate infusion rate. c. Administer injections by a variety of routes including intradermal, subcutaneous, intramuscular and intravenous. d. Be familiar with normal nutritional requirements. e. Be familiar with dietary treatment of health problems including weight reduction, diabetic, low fat, low cholesterol and low sodium diets. f. Be familiar with the drugs used most frequently in treatment or health problems including basic modes of action, indications, contraindications and complications. g. Be familiar with the management of common medical problems. i. Accurately calculate doses of medication, taking into account body weight, renal impairment of other issues. HEALTH PROMOTION/DISEASE PREVENTION 1. Recognize, develop and implement effective strategies for incorporating health promotion/disease prevention into rural primary care practice. a. Know the appropriate, recommended health screening services for each gender through the lifespan. b. Know the risk factors for preventable diseases. c. Know the personal health behaviors that can predispose to illness. d. Know the recommended immunizations for each gender throughout the lifespan. e. Know the various chemoprophylactic regimens that can be offered to patients before they develop clinical evidence of disease. f. Instruct the female patient in self-breast examination technique and its importance. g. Recognize the importance of patient education in effecting change in the health status of both individuals and groups. EMERGENCY SKILLS 1. Be able to recognize and manage life-threatening emergencies jointly with, and in the absence of, the physician. a. Recognize signs and symptoms of common emergencies and take appropriate action to sustain life. b. Apply basic techniques of CPR. 1. establish an airway 2. initiate or sustain effective ventilation 3. perform external cardiac massage 63
  • 64. c. Assist with or perform other techniques frequently indicated in life-threatening situations. 1. endotracheal/nasogastric intubation 2. cricothyrotomy 3. defibrillation/cardioversion 4. central line insertion 5. central venous pressure monitoring d. Initiate hemostasis in patients with hemorrhage. e. Assess and treat hemorrhagic shock. f. Support and treat patients with anaphylactic reaction. g. Communicate with the physician regarding the patient’s emergency status as soon as possible. h. Administer and/or advise regarding the first aid indicated in the overdose, accidental ingestion or attempted suicide with drugs and other chemical agents. i. Know the reference sources regarding toxic materials. j. Recognize potentially lethal cardiac dysrhythmias and know the current treatment for each. k. Recognize altered mental status and its common causes and treatment. l. Understand the use of and indications for standard emergency medications and administer if appropriate. m. Be familiar with triage procedures in mass casualty situations. n. Respect the decision of the patient and/or family for no advanced life support procedures. o. Assess patients with multiple trauma, skull and/or spinal injuries. COMMUNICATION 1. Be able to communicate in a medically professional manner, both orally and in writing, to the patient, the family and with health care professionals. a. Present to the physician a brief synopsis of the patient’s present illness, pertinent positive and negative findings and the diagnostic and therapeutic regimen instituted. b. Communicate effectively with both patient and family by using a vocabulary familiar to all concerned. c. Counsel patient and family regarding the health problem including an explanation of the disease process, therapy and its rationale, therapeutic options, prognosis and health care services available. d. Write routine and all other admission orders by the problem number. e. Write in a SOAP format, clear concise and relevant progress notes including diagnostic, therapeutic and patient education plans. f. Fill out routine laboratory test and diagnostic procedure request forms accurately and with pertinent data. g. Maintain a complete up-to-date problem list. h. Initiate requests for patient services including public health and home nursing, school testing and evaluation and release of medical records. i. Report communicable diseases utilizing appropriate forms and follow-up. j. Write interval notes. k. Perform discharge summaries. l. Give empathetic support to both patient and family in all communications. 64
  • 65. RESEARCH 1. Demonstrate an awareness of the recognized internal medicine literature, current issues and controversies in the literature and methods of accessing current literature while in rural sites. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 65
  • 66. Part III: Specific Clinical Rotation Objectives Primary Care Rotation: Obstetrics and Gynecology During the Obstetrics and Gynecology rotation, exposure to some or all of the following subject matter will be provided. This focus area may be completed in conjunction with other primary care focus areas at a family practice site or as a separate, shorter individual rotation. In addition to the PA Program Outcome Objectives and the General Clinical Year Objectives, the student will be responsible for the following Obstetrics and Gynecology objectives: HISTORY 1. Elicit an appropriate complete obstetrical and gynecologic history. a. Elicit a pertinent review of symptoms of pregnancy. b. Elicit a comprehensive obstetrical history c. Elicit a history of untoward reaction to anesthesia d. Elicit a history pertaining to sexuality, STD, menstrual cycles, and contraceptive use. 2. Calculate the EDC PHYSICAL EXAMINATION 1. Demonstrate the appropriate use of the fetoscope 2. Perform a pelvic examination a. Prenatal b. Postpartum c. Gynecologic d. Under anesthesia 3. Perform thorough examination of the prenatal abdomen. a. Measure uterine height b. Auscultate the fetal heart and note discrepancies from gestational dates c. Determine fetal lie 4. Perform Pelvimetry. 5. Assess and document membrane rupture. 6. Determine cervical dilation, effacement and station. 7. Examine the placenta for abnormalities 8. Examine the postpartum abdomen for uterine size DIAGNOSTIC STUDIES 1. Formulate a high risk pregnancy problem list 2. Apply fetal monitoring system electrodes 3. Interpret fetal monitoring tracings 4. Assist in performing amniocentesis 5. Assist/observe obstetric ultrasound 6. Assist in performing contraction stress and nonstress testing 7. Assess contractions, vital signs, and reflexes during labor. 8. Obtain Pap smears as indicated. 9. Obtain various cultures as indicated: 66
  • 67. a. Gonorrhea b. Chlamydia c. Herpes simplex d. Group B beta strep 10. Demonstrate skills necessary to perform and/or interpret basic laboratory tests. a. CBC b. stool, guaiac c. urinalysis, dipstick d. wet prep/KOH e. pregnancy test f. hormonal assays: LH, FSH, Prolactin, Testosterone, DHEAS, Thyroid Function Tests 11. Assist/perform biopsies: a. Vulvar b. Cervical c. Endocervical d. Endometrial 12. Be familiar with the techniques of: a. Post-coital test b. Basal body temperature charting and interpretation c. Artificial insemination d. Hysterosalpingogram e. Pelvic ultrasound 13. Participate in diagnostic laparoscopy, colposcopy CLINICAL KNOWLEDGE: Explain the etiology, diagnosis, and management options of health problems within the scope of PA practice. a. Explain the etiology and pathophysiology of common health problems seen in obstetrics and gynecology. b. List the diagnostic criteria of common health problems seen in obstetrics and gynecology. c. Describe the management options for common health problems seen in obstetrics and gynecology. DIFFERENTIAL DIAGNOSIS 1. Demonstrate and discuss the common obstetric and gynecologic conditions and problems and their typical presentations including: OBSTETRICS Fetal development Placenta previa Prenatal care Ectopid pregnancy Normal labor and delivery Abortion High risk pregnancy Intrauterine death Toxemia of pregnancy/PIH Cesarean section Medical complications of pregnancy Genetic counseling Obstetrical anesthesia Amniocentesis Postpartum care Ultrasonography/Fetal monitoring Abruptio Placenta Fetal activity testing 67
  • 68. GYNECOLOGY Menstruation/normal and altered Dysmenorrhea throughout the life cycle Premenstrual syndrome Menopause Menopause Premenstrual syndrome Breast Infertility Abscess Sexual dysfunction Carcinoma Common gynecologic surgeries Fibroadenoma Uterus Fibrocystic disease Dysfunctional uterine bleeding Mastitis Endometrial cancer Pelvic Inflammatory Disease Endometriosis/adenomyosis Contraceptive Methods Leiomyoma Infertility Metritis Uncomplicated Pregnancy Prolapse Prenatal diagnosis/care Ovary Normal labor/delivery Cysts Complicated Pregnancy Neoplasms Abortion Cervix Abruptio placentae Carcinoma Dystocia Cervicitis Ectopic pregnancy Dysplasia Fetal distress Incompetent Gestational diabetes Vagina/Vulva Gestational trophoblastic disease Cystocele Molar pregnancy Neoplasm Multiple gestation Prolapse Placenta previa Rectocele Postpartum hemorrhage Vaginitis Pregnancy-induced hypertension Menstrual Disorders Premature rupture of membranes Amenorrhea Rh incompatibility THERAPEUTICS 1. Know the accepted treatment for the above conditions. 2. Describe and discuss the dietary treatment of obstetrical problems and special dietary needs of the obstetrical patient. 3. Give support to the patient in labor. 4. Employ proper delivery room protocol. 5. Manage a normal delivery. 6. Recognize the indication for episiotomies. 7. Know which drugs are safe to use during pregnancy and lactation and which should not be used and why. 8. Insert/Remove IUD’s and manage side-effects or complications related to them. 9. Fit diaphragms and cervical caps. 68
  • 69. 10. Insert/remove Norplant and manage side-effects or complications related to them. 11. Prescribe oral contraceptives and Depo-Provera and manage side-effects or complications related to them. HEALTH PROMOTION/DISEASE PREVENTION 1. Know, and counsel the obstetric patient about, the current recommendations regarding: a. Screening for HIV b. Screening for chlamydial infections c. Screening for genital herpes d. Screening for asymptomatic bacteriuria e. Screening for rubella f. Screening ultrasonography g. Screening for preeclampsia h. Screening for RH incompatibility i. Screening for neural tube defects j. Screening for hemoglobinopathies k. Screening for PKU l. Screening for congenital hypothyroidism m. Intrapartum electronic fetal monitoring 2. Know, and counsel the gynecologic patient about, the current recommendations regarding: a. Screening for breast cancer, including self-breast exam and mammography b. Screening for cervical cancer c. Screening for ovarian cancer d. Screening for osteoporosis e. Prevention of osteoporosis f. Hormone replacement therapy in the postmenopausal patient g. Screening for sexually transmitted diseases EMERGENCY SKILLS 1. Recognize and institute the initial management of emergency gynecologic and obstetric emergencies in the absence of the physician, such as: a. ectopic pregnancy b. obstetrical hemorrhage c. preeclampsia/eclampsia/PIH d. preterm labor e. intrapartum fetal distress f. postpartum hemorrhage/infection g. sepsis h. embolic phenomena i. dysfunctional uterine bleeding j. pelvic inflammatory disease k. torsion of ovarian cyst l. know the protocol for medical evaluation of rape/domestic abuse COMMUNICATION 69
  • 70. 1. Counsel patients and their family regarding pregnancy and childbirth, explaining the normal processes, complications and instruct regarding the importance of adequate nutrition and prenatal and postpartum care. 2. Counsel patients regarding breastfeeding vs. bottlefeeding. 3. Maintain a complete prenatal and L&D record. 4. Counsel patients regarding birth control and sexual concerns. 5. Counsel patients regarding premenstrual syndrome. 6. Counsel patients regarding menopausal symptoms, osteoporosis, and hormone replacement therapy. 7. Counsel patients regarding sexually transmitted diseases. 8. Counsel patients regarding infertility. 9. Counsel patients regarding keeping a basal body temperature chart and in the use of ovulation predictor kits. 10. Counsel patients regarding the normal menstrual cycle and expected changes over the lifespan. 11. Counsel patients regarding rape and domestic abuse. RESEARCH a. Demonstrate an awareness of the recognized obstetric and gynecologic medical literature, current issues and controversies in the literature and methods of accessing current literature while in rural sites. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 70
  • 71. Part III: Specific Clinical Rotation Objectives Primary Care Rotation: Pediatrics During the Pediatric rotation, exposure to some or all of the following subject matter will be provided. This focus area may be completed in conjunction with other primary care focus areas at a family practice site or as a separate, shorter individual rotation. In addition to the PA Program Outcome Objectives and the General Clinical Year Objectives, the student will be responsible for the following Pediatric objectives: HISTORY 1. Obtain a complete or partial history from or regarding pediatric patients of any age. 2. Elicit a well baby history including physical growth, mental and emotional development, immunizations, and the historical components of Denver Developmental Screening Exam. 3. Elicit dietary history including formula used, amount taken, feeding per twenty four hours, dates starting new foods, food intolerance, and history of pica. 4. Utilize techniques required to obtain an adolescent history including school performance, peer interactions, substance abuse, sexual activity, and tobacco use. PHYSICAL EXAMINATION 1. Be able to perform a complete and partial physical examination on pediatric patients. 2. Develop skills which assist in the examination of the uncooperative child. 3. Perform examination of the newborn 4. Demonstrate APGAR Scoring 5. Determine gestational age by examination. 6. Measure, record and chart height, weight, and head circumference on standard nomograms. 7. Utilize screening exams to augment the basic physical examination. DIAGNOSTIC STUDIES 1. Identify, perform, order and/or interpret appropriate, cost-effective, routine diagnostic procedures, based on history and physical examination findings, and be able to assist the physician with other diagnostic procedures as directed. a. Identify the appropriate and available diagnostic tests for a particular problem based on the history and physical examination findings. b. Identify and discuss indications and contraindications of the various diagnostic tests. c. Identify and describe the risks, costs and patient inconvenience of various diagnostic tests. d. Demonstrate skills required to collect routine specimens. 1. bacteriologic samples 2. blood, venous and arterial 3. gastric contents 4. sputum 5. stool 6. tissues 7. urine e. Demonstrate skills necessary to perform and/or interpret basic laboratory tests. 71
  • 72. 1. CBC 2. gram stain 3. stool, O&P 4. stool, guaiac 5. urinalysis, dipstick 6. wet prep/KOH 7. pregnancy test 8. alcohol screening f. Demonstrate skills necessary to perform and interpret a 12 lead EKG and rhythm strip. g. Administer, interpret and record results of intradermal skin test. h. Demonstrate skills necessary to perform and interpret screening audiometric testing. i. Identify, order and/or perform and/or interpret other selected diagnostic tests. j. Order and make preliminary assessment of routine radiologic studies, including PA and lateral chests, KUB, GI, and extremity films. k. Know routine preparation for common Xray studies. l. Be familiar with techniques of anoscopy, proctoscopy, sigmoidoscopy, bronchoscopy, gastroscopy and endoscopy and colonoscopy. m. Be familiar with techniques of thoracentesis, paracentesis, arthrocentesis, pericardiocentesis and lumbar puncture. n. Be familiar with routine nuclear medicine studies/reports. o. Be familiar with the technique of excisional biopsy. p. Recognize the signs and symptoms of complications of diagnostic procedures performed or ordered. CLINICAL KNOWLEDGE: Explain the etiology, diagnosis, and management options of health problems within the scope of PA practice. a. Explain the etiology and pathophysiology of common health problems seen in pediatrics. b. List the diagnostic criteria of common health problems seen in pediatrics. c. Describe the management options for common health problems seen in pediatrics. DIFFERENTIAL DIAGNOSIS 1. Describe and discuss common pediatric problems and concerns and their modes of presentation including: GENERAL Newborn exam Growth and development Problems in the neonate Genetic disorders/Counseling Fluids and electrolytes Fever of unknown origin Poisonings Communicable disease Mental retardation Immunizations Child abuse Learning disabilities Failure to thrive Adolescent medicine Well baby/Child exams Depression/Suicide Acid base balance 72
  • 73. CARDIOLOGY Congenital Heart Disease Atrial septal defect Coarctation of aorta Patent ductus arteriosus Tetralogy of Fallot Ventricular septal defect RESPIRATORY URI Otitis Media/Otitis Externa Pharyngitis Croup/Epiglottitis Pneumonia Bronchitis/Bronchiolitis Respiratory Distress Syndrome Asthma Cystic Fibrosis GASTROINTESTINAL Infection: bacterial, viral, parasitic Diarrhea/Dehydration Hyperbilirubinemia Constipation Congenital anomalies GENITOURINARY Urinary Tract infections Hematuria Vaginitis Tumors Vesicoureteral reflux ORTHOPAEDICS Common Fractures Dislocations/Subluxations Congenital abnormalities ENDOCRINE Diabetes Congenital Endocrinopathies Thyroid Disease NEUROLOGY Meningitis Encephalitis Seizure Disorder Pediatric Headaches DERMATOLOGY Viral exanthems Miliaria Parasitic Infections Eczema Acne Tinea/Monilial Infections Contact Dermatitis Allergic Dermatitis Impetigo THERAPEUTICS 73
  • 74. 1. Monitor serum drug levels in patients on long term treatment. 2. Remove cerumen from the external auditory canal using various techniques. 3. Perform and or interpret audiometry and/or tympanometry. 4. Administer immunizations using the recommended schedule. 5. Demonstrate techniques that are unique to the pediatric patient in advanced life support. 6. Obtain IV access on the pediatric patient. 7. Perform urethral catherization on the pediatric patient. 8. Demonstrate appropriate treatment of the above conditions. HEALTH PROMOTION/DISEASE PREVENTION 1. Recognize, develop and implement effective strategies for incorporating health promotion/disease prevention into rural primary care practice. a. Know the appropriate, recommended health screening services for each gender through the lifespan. b. Know the risk factors for preventable diseases. c. Know the personal health behaviors that can predispose to illness. d. Know the recommended immunizations for each gender throughout the lifespan. e. Know the various chemoprophylactic regimens that can be offered to patients before they develop clinical evidence of disease. f. Instruct the female patient in self-breast examination technique and its importance. g. Recognize the importance of patient education in effecting change in the health status of both individuals and groups. EMERGENCY SKILLS 1. Be able to recognize and manage life-threatening emergencies jointly with, and in the absence of, the physician. a. Recognize signs and symptoms of common emergencies and take appropriate action to sustain life. b. Apply basic techniques of CPR and Pediatric Advanced Life Support. 1. establish an airway 2. initiate or sustain effective ventilation 3. perform external cardiac massage c. Assist with or perform other techniques frequently indicated in life-threatening situations. 1. endotracheal/nasogastric intubation 2. defibrillation/cardioversion 3. central line insertion d. Initiate hemostasis in patients with hemorrhage. e. Assess and treat hemorrhagic shock. f. Support and treat patients with anaphylactic reaction. g. Communicate with the physician regarding the patient’s emergency status as soon as possible. h. Administer and/or advise regarding the first aid indicated in the overdose, accidental ingestion or attempted suicide with drugs and other chemical agents. i. Know the reference sources regarding toxic materials. j. Recognize potentially lethal cardiac dysrhythmias and know the current treatment for each. 74
  • 75. k. Recognize altered mental status and its common causes and treatment. l. Understand the use of and indications for standard emergency medications and administer if appropriate. m. Be familiar with triage procedures in mass casualty situations. n. Respect the decision of the patient and/or family for no advanced life support procedures. o. Assess patients with multiple trauma, skull and/or spinal injuries. COMMUNICATION 1. Counsel the patient and parents on a variety of subjects including, but not limited to, growth and development, nutrition, childhood fears, accident prevention, preparation for school, obesity, immunizations, and discipline. 2. Counsel the adolescent regarding common adolescent concerns a. Explain the process of physical and emotional maturing. b. Reassure the patient about sexually related matters including development, menstruation, masturbation, sexual intercourse, birth control, and abortion. c. Explain disease processes as they relate to the adolescent’s medical problems. d. Counsel the adolescent in problems related to smoking, drugs and alcohol use. RESEARCH 1. Demonstrate an awareness of the recognized pediatric medical literature, current issues and controversies in the literature and methods of accessing current literature while in rural sites. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 75
  • 76. Part III: Specific Clinical Rotation Objectives Specialty Care Rotations The following are the objectives for the main focus areas in the Specialty Care Medicine Clinical Rotation. They cover the focus areas of Surgery, Emergency Medicine, Psychiatry, and Electives. Specialty Care Rotation: Surgery During the surgical rotation, exposure to some or all of the following subject matter will be provided. In addition to the Outcome Objectives and the General Clinical Year Objectives previously listed, the student will be responsible for the following Surgery objectives: HISTORY 1. Elicit a history of untoward reactions to anesthesia. 2. Elicit a history of diseases which affect the advisability of surgery. 3. Elicit a history of recurrent or progressive surgical problems. 4. Elicit a history pertaining to prior surgical complications. 5. Elicit a post-operative history. PHYSICAL EXAMINATION Perform an appropriate physical examination for the surgical patient DIAGNOSTIC STUDIES 1. Identify, perform, order and/or interpret appropriate, cost-effective, routine diagnostic procedures, based on history and physical examination findings, and be able to assist the physician with other diagnostic procedures as directed. a. Identify the appropriate and available diagnostic tests for a particular problem based on the history and physical examination findings. b. Identify and discuss indications and contraindications of the various diagnostic tests. c. Identify and describe the risks, costs and patient inconvenience of various diagnostic tests. d. Demonstrate skills required to collect routine specimens. 1. bacteriologic samples 2. blood, venous and arterial 3. gastric contents 4. sputum 5. stool 6. tissues 7. urine e. Demonstrate skills necessary to perform and/or interpret basic laboratory tests. 1. CBC 2. gram stain 76
  • 77. 3. stool, O&P 4. stool, guaiac 5. urinalysis, dipstick 6. wet prep/KOH 7. pregnancy test 8. alcohol screening f. Demonstrate skills necessary to perform and interpret a 12 lead EKG and rhythm strip. g. Administer, interpret and record results of intradermal skin test. h. Demonstrate skills necessary to perform and interpret screening tonometry and audiometry tests. i. Identify, order and/or perform and/or interpret other selected diagnostic tests. j. Order and make preliminary assessment of routine radiologic studies, including PA and lateral chests, KUB, GI, GB and extremity films. k. Know routine preparation for common Xray studies. l. Be familiar with techniques of anoscopy, proctoscopy, sigmoidoscopy, bronchoscopy, gastroscopy and endoscopy and colonoscopy. m. Be familiar with techniques of thoracentesis, paracentesis, arthrocentesis, pericardiocentesis and lumbar puncture. n. Be familiar with routine nuclear medicine studies/reports. o. Be familiar with the technique of excisional biopsy. p. Recognize the signs and symptoms of complications of diagnostic procedures performed or ordered. CLINICAL KNOWLEDGE: Explain the etiology, diagnosis, and management options of health problems within the scope of PA practice. a. Explain the etiology and pathophysiology of common health problems seen in surgery. b. List the diagnostic criteria of common health problems seen in surgery. c. Describe the management options for common health problems seen in surgery DIFFERENTIAL DIAGNOSIS 1. Describe and discuss common surgical problems, concerns and their modes of presentation, including: GENERAL Pre/Post operative care Fluid and electrolyte balance and acid base Wound care and infections Surgical nutrition/Hyperalimentation Anesthesia Shock Aseptic technique Trauma care Principles of suturing Burns Organ transplantation SYSTEMS Breasts-Tumors/reconstruction CARDIOVASCULAR Arterial by-pass grafting Venous ligation 77
  • 78. Aneurysms Arterial reconstruction THORAX Lung biopsy/resection ABDOMEN Acute surgical abdomen Cholecystectomy Appendectomy Liver Bx Bowel resection Herniorrhaphy Laparscopic procedures Gastric Procedures-fundoplication/V&P/ UROLOGY Prostatectomy Prostatic/Testicular tumors Nephrolithiasis TURP Vasectomy ORTHOPAEDICS Common Knee Injuries Arthroscopy/Arthroplasty Common Shoulder Injuries Hand Injuries ORIF Fractures NEUROSURGERY Cervical/lumbar disc disease VP Shunts for hydrocephalus Common cranial tumors Management of increased intercranial pressure Repair AVM THERAPEUTIC SKILLS The PA student will demonstrate the following knowledge, skills and abilities during their surgical rotation. 1. Discuss the composition of fluids that are frequently lost from the body including urine, gastric secretions, diarrhea, third space fluids, and hemorrhage. 2. Discuss the relationships between serum electrolytes and IV therapy and the need to adjust therapy based on lab results and physical signs. 3. Recognize the problems associated with hypo and hypervolemia. 4. Describe blood and blood products utilized in IV therapy and the indications, precautions, contraindications, and complications of their use. 5. Recognize the drugs most frequently used in treatment of surgical problems, including basic modes of actions, indication, contraindications, and complications. 6. Describe pre-op and post-op management of surgical patients. 7. Discuss anesthetics, their indications, modes of action, contraindications, complications, and combinations in: a. General anesthesia b. Spinal and regional anesthesia c. Regional anesthesia/field blocks 8. Utilize infiltration anesthesia. 78
  • 79. 9. Apply casts, splints, or wraps to immobilize the injured structure. 10. Assemble surgical instruments necessary for wound closure and use these instrument appropriately. 11. Set up a sterile field and prep the injured area. 12. Employ proper techniques for closing wounds. a. Aseptic technique b. Hemostasis c. Closure of dead space d. Approximation of like tissues e. Know various techniques for dermal closure 1. Simple stitch 2. Vertical/horizontal mattress 3. Running stitch 4. Running subcuticular 5. Specialty closure techniques 13. Discuss the different types of suture materials and their uses including silk, gut, chromic, nylon, dacron, vicryl, and PDS. 14. Demonstrate I&D of an abscess. 15. Instruct the patient in proper wound care. 16. Assess wound healing. 17. Remove sutures/staples. 18. Describe fluid therapy in burn patients. 19. Demonstrate proper use of topical antibiotics. 20. Demonstrate how to dress wounds including burn dressings. 21. Demonstrate management of burn patients, including nutrition and burn complications. 22. Demonstrate/Discuss the management of common surgical problems as listed above. HEALTH PROMOTION/DISEASE PREVENTION 1. Recognize, develop and implement effective strategies for incorporating health promotion/disease prevention into rural primary care practice. a. Know the appropriate, recommended health screening services for each gender through the lifespan. b. Know the risk factors for preventable diseases. c. Know the personal health behaviors that can predispose to illness. d. Know the recommended immunizations for each gender throughout the lifespan. e. Know the various chemoprophylactic regimens that can be offered to patients before they develop clinical evidence of disease. f. Instruct the female patient in self-breast examination technique and its importance. g. Recognize the importance of patient education in effecting change in the health status of both individuals and groups. EMERGENCY SKILLS 1. Be able to recognize and manage life-threatening emergencies jointly with, and in the absence of, the physician. a.. Apply basic techniques of CPR. 1. establish an airway 79
  • 80. 2. initiate or sustain effective ventilation 3. perform external cardiac massage b Assist with or perform other techniques frequently indicated in life-threatening situations. 1. endotracheal/nasogastric intubation 2. cricothyrotomy 3. defibrillation/cardioversion 4. central line insertion 5. central venous pressure monitoring c Initiate hemostasis in patients with hemorrhage. d. Assess and treat hemorrhagic shock. e. Support and treat patients with anaphylactic reaction. f. Communicate with the physician regarding the patient’s emergency status as soon as possible. g. Administer and/or advise regarding the first aid indicated in the overdose, accidental ingestion or attempted suicide with drugs and other chemical agents. h. Know the reference sources regarding toxic materials. i. Recognize potentially lethal cardiac dysrhythmias and know the current treatment for each. j. Recognize altered mental status and its common causes and treatment. k. Understand the use of and indications for standard emergency medications and administer if appropriate. l. Be familiar with triage procedures in mass casualty situations. m. Respect the decision of the patient and/or family for no advanced life support procedures. n. Assess patients with multiple trauma, skull and/or spinal injuries. COMMUNICATION 1. Be able to communicate in a medically professional manner, both orally and in writing, to the patient, the family and with health care professionals. a. Present to the physician a brief synopsis of the patient’s present illness, pertinent positive and negative findings and the diagnostic and therapeutic regimen instituted. b. Communicate effectively with both patient and family by using a vocabulary familiar to all concerned. c. Counsel patient and family regarding the health problem including an explanation of the disease process, therapy and its rationale, therapeutic options, prognosis and health care services available. d. Write routine and all other admission orders by the problem number. e. Write in a SOAP format, clear concise and relevant progress notes including diagnostic, therapeutic and patient education plans. f. Fill out routine laboratory test and diagnostic procedure request forms accurately and with pertinent data. g. Maintain a complete up-to-date problem list. h. Initiate requests for patient services including public health and home nursing, school testing and evaluation and release of medical records. i. Report communicable diseases utilizing appropriate forms and follow-up. j. Write interval notes. k. Perform discharge summaries. 80
  • 81. l. Give empathetic support to both patient and family in all communications. RESEARCH 1. Demonstrate knowledge of medical research methodologies and their application to rural primary care medicine. 2. Demonstrate the ability to obtain current surgical literature when located in remote areas. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 81
  • 82. Part III: Specific Clinical Rotation Objectives Specialty Care Rotation: Psychiatry During the focus area of Psychiatry, exposure to some or all of the following subject matter will be provided. The student will gain experience and proficiency working as a member of an organized health care team working in Psychiatry. Emphasis should be placed on developing those skills and cognitive knowledge which will help the student perform well in a primary care setting. Additional objectives to be attained by the student are as follows: HISTORY 1. Elicit an appropriate complete psychiatric a. history and medical review of systems that may present as psychiatric disease b. past medical history c. risk factors profile d. database stressing the cognitive and affective information and develop skills which will enable recognition of normal and deviation from normal 2. Record the database acquired on the office or hospital record using the traditional or problem oriented medical record system 3. Be able to understand the common psychiatric terminology and it’s relationship to pathologic states including: a. fetishism z. grandiosity b. transetism aa. flatness c. zoophilia bb. anhedonia d. pedophilia cc. confabulation e. exhibitionism dd. depersonalization f. voyeurism ee. distortion g. sexual masochism ff. illusions h. sexual sadism gg. hallucinations i. atypical paraphilia hh. hypochondriasis j. pyknic ii. paranoid ideation k. asthenic jj. reference l. spastic kk. persecution m. verbal aphasia ll. loose associations n. syntactical aphasia mm. clang associations o. nominal aphasia nn. echolalia p. semantic aphasia oo. confabulation q. astereognosis pp. blocking r. anosognosia qq. circumstantiality s. autotopagnosia rr. silliness t. somatization ss. incorrect conclusions u. ambivalence tt. religiosity v. la belle indifference uu. ideas of guilt w. indifference vv. ideas of worthlessness x. waxy flexibility ww. poverty of content y. euphoria xx. rhyming 82
  • 83. yy. omnipotence iii. delusions zz. projection jjj. flight of ideas aaa. word salad kkk. perseveration bbb. introjection lll. tangentiality ccc. tics mmm. displacement ddd. echopraxia nnn. denial eee. stereotyped motor disorder ooo. regression fff. posturing ppp. sublimation ggg. waxy flexibility qqq. identification hhh. cationic rigidity rrr. displacement PHYSICAL EXAMINATION 1. Perform a directed physical examination on the patient with suspected psychiatric disease. 2. Perform and interpret the results of a complete mental status examination including: a. appearance and behavior b. thought process and perceptions 1. coherency and relevance 2. thought content 3. perception c. cognitive factors 1. orientation 2. attention and concentration 3. memory 4. information and vocabulary 5. abstract reasoning 6. judgment 7. perception and coordination d. evaluation of suicidal risks 3. Perform and interpret the Folstein Mini-Mental Status Exam 4. Identify abnormal findings on the physical examination that may lead the clinician to consider a secondary cause for the psychiatric manifestation of the patient. 5. Record the physical examination on the office or hospital record using the traditional or problem oriented medical record. DIAGNOSTIC 1. Given the database collected: a. develop a problem list and tentative diagnosis b. develop a plan of investigation and order appropriate laboratory and diagnostic tests c. understand and apply the current method of diagnostic criteria for psychiatric disorders 2. Identify and be able to discuss the indication for performing standardized psychiatric screening, and other examinations: a. EEG b. Brain Scan c. Cat Scan d. intelligence tests (Wechsler Adult Intelligence scale) e. tests of perceptual and motor function (Bender Gestalts) 83
  • 84. f. personality inventories (MMPI) g. projective tests (Rorschach, Thematic Apperception Test) h. Denver Developmental Screening Test CLINICAL KNOWLEDGE: Explain the etiology, diagnosis, and management options of health problems within the scope of PA practice. a. Explain the etiology and pathophysiology of common health problems seen psychiatry. b. List the diagnostic criteria of common health problems seen in psychiatry. c. Describe the management options for common health problems seen in psychiatry DIFFERENTIAL DIAGNOSIS 1. List the criteria, clinical features, differential diagnosis, and treatment of the following psychiatric and associated disorders. a. affective disorders 1. bipolar disorder I and II 2. major depression 3. cyclothymic disorder 4. dysthymic disorder b. anxiety disorders 1. phobic disorders 2. panic disorder 3. anxiety states 4. post traumatic stress disorder c. somatoform disorders 1. somatization disorder 2. conversion disorder 3. psychogenic pain disorder 4. hypochondriasis d. psychosexual dysfunction e. adjustment disorders f. pediatric disorders 1. mental retardation 2. attention deficit disorder 3. conduct disorder 4. anxiety disorder 5. eating disorders: anorexia nervosa/bulimia g. organic mental disorder h. substance abuse disorders i. schizophrenic disorders j. delusional disorders k. brief reactive psychosis l. personality disorders 1. paranoid 2. schizoid 3. schizotypal 4. histrionic 84
  • 85. 5. narcissistic 6. antisocial 7. borderline 8. avoidant 9. dependent 10. compulsive 11. passive-aggressive m. other conditions 1. malingering 2. uncomplicated bereavement 3. marital problems 4. parent child problems n. autism o. stress related medical disorders THERAPEUTICS 1. Understand the treatment modalities listed including indications, contraindications, and side effects of: a. psychotherapy b. electroconvulsive therapy c. hospitalizations d. social approaches e. common psychiatric pharmacologic agents including: 1. anxiolytics 2. anti-psychotics 3. sedative hypnotics 4. phenothiazine derivatives 5. antidepressants HEALTH PROMOTION AND DISEASE PREVENTION 1. Know and counsel the psychiatric patient about the current recommendations regarding: a. importance of medication compliance to maintain disease control b. importance of non pharmacologic mechanisms in prevention of stress mediated psychiatric disease c. availability of community based psychiatric services EMERGENCY SKILLS 1. List the indications for immediate psychiatric referral and evaluation by a psychiatrist 2. List the indications for involuntary commitment of the psychiatric patient 3. List the indications, contraindications, and adverse reactions of commonly used psychotropic drugs in an emergency setting COMMUNICATION 1. Be able to present both orally and in writing a complete database in a concise and orderly fashion 2. Develop an appreciation for the contribution of other health care providers in evaluating, 85
  • 86. managing and treating psychiatric disease and communicate effectively the breadth and scope of services needed when referring a psychiatric patient RESEARCH 1. Demonstrate an awareness of the recognized psychiatric literature, current issues and controversies in the literature and methods of accessing current literature while in rural sites. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 86
  • 87. Part III: Specific Clinical Rotation Objectives Specialty Care Rotation: Emergency Medicine In addition to the PA Program Outcome Objectives and the General Clinical Year Objectives, the student will be responsible for the following Emergency Medicine objectives: 1. Develop an awareness of: a. The need for methodical, rapid, and accurate assessment of the acutely ill or injured patient is the primary concern of the emergency department. b. Patient anxiety and apprehension during times of crisis and the need for empathy, confidence, and appropriate reassurance that should be exhibited by the student c. The need to inform and educate the patient’s family regarding the current emergent condition and progress. 2. General Objectives: a. Elicit an appropriate complete or partial history from the patient or “third” party should the patient be unconscious or a child. b. Perform a methodical, rapid, comprehensive, and accurate immediate assessment of patients presenting to the emergency department with life threatening emergencies. c. Perform a methodical, rapid, comprehensive, and accurate secondary assessment of patients presenting to the emergency department, being careful to examine for the following: 1. Vital signs, facial and extremity coloration 2. Head 3. Chest 4. Abdomen 5. Extremities 6. Pelvis 7. Perineum 8. Back and Buttocks d. Given a patient presentation either historical, physical, or laboratory based: 1. Develop a problem list and tentative diagnosis 2. Develop a plan of investigation and order the appropriate laboratory and diagnostic tests 3. Develop a plan of therapy appropriate for the patients condition e. Record the data base on the emergency room record using both traditional and problem oriented medical record approach. f. Present orally the complete database in a concise and orderly fashion 3. Specific Objectives a. Given a patient or appropriate historical, physical or laboratory data, be able to diagnose and initiate treatment for the following common conditions seen in the emergency department 1. Fractures and dislocations 2. Deteriorating or changing mental status 3. Penetrating ocular injuries 87
  • 88. 4. Acute endocrine emergencies(diabetic coma, adrenal insufficiency, thyroid storm, etc) 5. Chest Pain (Angina/MI) 6. Abdominal Pain, (Appendicitis, Cholecystitis, Bowel Obstruction, Perforated Ulcer, Renal Colic, etc) 7. Ingestion of Poisons etc 8. Drug Overdose/Abuse 9. First, Second, or Third degree thermal, chemical, or electrical burns 10. Hypertensive Emergency/Urgency 11. Acute arterial occlusion 12. Intrapartum Hemorrhage 13. Threatened/Spontaneous AB 14. Precipitous delivery 15. Seizures 16. Severe Dehydration 17. Shock 18. Arrhythmias/Cardiac Arrest 19. Congestive Heat Failure/Pulmonary Edema 20. Acute Respiratory Distress Syndrome/ Respiratory Arrest b. Identify indications and complications of ACLS and perform Advanced Life support on 1. Newborn 2. Young Child 3. Adult c. Identify the presentation of and describe appropriate therapy for harmful bites from: 1. Humans 2. Snakes (Hemotoxic and Neurotoxic Venom) 3. Spiders 4. Animals 5. Insects d. Identify and initiate treatment for the following common conditions seen in the emergency room 1. Allergic 15. Epistaxis/emoptysis Reactions/Anaphylaxis 16. Conjunctivitis 2. Lacerations/abrasions 17. URIs 3. Puncture/Stab wounds 18. Pneumonia 4. Cellulits 19. Otitis Externa 5. Rashes 20. Exac COPD 6. Hematoma 21. CVA 7. Herpes Zoster 22. Gastroenteritis 8. Pharyngitis 23. Gastritis 9. Headache 24. Hepatitis 10. Sinusitis 25. Hiatal Hernia/GERD 11. Pyelonephritis 26. Peptic Ulcer Disease 12. Glomerulonephritis 27. UTI 13. Otitis Media 28. STDs 14. Tonsillitis 29. Kidney Stones 88
  • 89. 30. Vaginitis 31. PID 32. Sprains/Strains 33. Back Pain 34. Muscle Spasm 35. Costal Chondritis 36. Acute Anxiety 37. Depression 38. Alcohol Abuse 39. Gunshot wounds 40. Syncope 89
  • 90. Part III: Specific Clinical Rotation Objectives Elective Rotations This section contains objectives for some common Elective rotations. Elective Rotation: Cardiology During the student’s rotation in Cardiology, exposure to some or all of the following subject matter will be provided. The student will gain experience and proficiency working as a member of an organized health care team. Emphasis should be placed on developing those skills and cognitive knowledge which will help the student perform well in a primary care setting. Additional objectives to be attained by the student are as follows: BASIC SCIENCE 1. Describe the anatomy of the cardiovascular system 2. Describe the physiologic function of the cardiovascular system 3. Describe pathophysiologic mechanisms involved in the following a. Ischemic Heart Disease and Acute MI b. Congestive Heart Failure c. Cardiomyopathies and Myocarditis d. Pericardial Disease e. Hypertension f. Arteriosclerosis g. Cardiac Arrhythmias h. Cardiogenic Shock HISTORY 1. Elicit and record an appropriate cardiovascular history including: a. Cardiovascular review of systems b. Past medical history pertinent to the cardiovascular system c. Social history pertinent to the cardiovascular system d. Family history pertinent to the cardiovascular system e. Current medications f. Drug allergies g. Cardiovascular disease risk factors 2. Recognize the classic historical presentation of the following etiologies of chest pain and shortness of breath a. Angina Pectoris b. Acute Myocardial Infarction c. Congestive Heart Failure d. Pericarditis e. COPD f. Musculoskeletal including muscle strain and costochondritis 90
  • 91. g. Neurogenic including Herpes Zoster and radiculopathies h. Pulmonary Embolus i. Pneumonia j. Pleuritis k. Pneumothorax/hemothorax PHYSICAL EXAMINATION 1. Given a patient or historical, and laboratory data perform a comprehensive cardiovascular examination 2. Describe various normal and abnormal findings on the cardiovascular examination and further describe their etiology including: a. Normal heart sounds (S1, S2, physiologic splitting, Physiologic S3) b. Abnormal heart sounds(S3, S4, murmurs, rubs, valvular opening sounds, etc) c. Lifts, heaves and thrills d. Diminished or absent pulses e. Bruits f. Venous hums g. JVD and Hepatojugular reflux h. Skin changes consistent with various types of cardiovascular disease(cyanosis etc) CLINICAL KNOWLEDGE: Explain the etiology, diagnosis, and management options of health problems within cardiology. DIFFERENTIAL DIAGNOSIS 1. Given a patient or historical, physical and laboratory findings differentiate between the following: a. Stable and unstable angina b. Acute myocardial infarction c. Variant angina d. Pericarditis e. Cardiomyopathy f. Pulmonary embolus g. Pneumonia h. Pneumothorax i. Herpes Zoster or other chest pain of neurogenic etiology j. Atypical chest pain k. Musculoskeletal chest pain l. Psychogenic chest pain m. DIAGNOSTIC STUDIES 1. Given a rhythm strip differentiate between the following arrhythmias/conditions: a. Tachy-arrhthymias 1. Atria Fib Flutter 2. PSVT 3. Sinus tachycardia 91
  • 92. 4. Ventricular tachycardia/fibrillation 5. WPW syndrome b. Brady-arrhthymias c. Sinus bradycardia 1. 1st, 2nd, and 3rd degree heart block 2. Asystole d. Premature contractions from various locations (APC’s VPC’s, JPC’s, etc) 3. Given a 12 lead EKG be able to identify the following conditions: a. Myocardial infarct patterns b. Pericarditis c. Bundle branch blocks d. LVH e. RVH 4. Describe the possible etiologies of abnormal cardiac enzymes including a. CPK/Fractions b. SGOT c. LDH 5. Classify various lipid abnormalities (hyper and dyslipidemias), describe secondary etiologies and prescribe treatment based on NCEP guidelines. THERAPEUTICS 1. Describe an approach to management, following JNC guidelines, of hypertension. 2. Describe an approach to management of the patient with ischemic heart disease including acute MI and angina pectoris. 3. Describe an approach to management of asystole, tachy & brady arrhythmias. 4. Describe and approach to managing the patient with CHF. HEALTH PROMOTION AND DISEASE PREVENTION 1. List the risk factors for atherosclerotic cardiovascular disease. 2. Given a patient database prescribe preventive measures to be taken to overcome reversible risk factors. 3. Counsel patients on the advantages of exercise, smoking cessation, and prudent diet. COMMUNICATION 1. Be able to communicate in a medically professional manner, both orally and in writing, to the patient, the family and with health care professionals. a. Present to the physician a brief synopsis of the patient’s present illness, pertinent positive and negative findings and the diagnostic and therapeutic regimen instituted. b. Communicate effectively with both patient and family by using a vocabulary familiar to all concerned. c. Counsel patient and family regarding the health problem including an explanation of the disease process, therapy and its rationale, therapeutic options, prognosis and health care services available. d. Write routine and all other admission orders by the problem number. e. Write in a SOAP format, clear concise and relevant progress notes including diagnostic, therapeutic and patient education plans. 92
  • 93. f. Fill out routine laboratory test and diagnostic procedure request forms accurately and with pertinent data. g. Maintain a complete up-to-date problem list. h. Initiate requests for patient services including public health and home nursing, school testing and evaluation and release of medical records. i. Report communicable diseases utilizing appropriate forms and follow-up. j. Write interval notes. k. Perform discharge summaries. l. Give empathetic support to both patient and family in all communications. 2. Understand the roles of the various health care providers in performing primary screening or cardiovascular disease. 3. Communicate effectively the breadth and scope of services needed when consulting and/or referring a patient for cardiac consultation. 93
  • 94. Part III: Specific Clinical Rotation Objectives Elective Rotations: Dermatology The objectives to be attained by the student are as follows: BASIC SCIENCE 1. Describe the anatomy and components of the integumentary system. 2. Describe the physiologic function of the integumentary system. 3. Describe the physiologic and pathophysiological affects of UV radiation on the skin. HISTORY 1. Elicit an appropriate complete dermatologic history. a. Elicit an appropriate dermatologic review of systems and medical review of systems that may lead the clinician to discover dermatologic manifestations of systemic disease. b. Elicit an appropriate dermatologic and systemic past medical history. c. Elicit an appropriate social and occupational history pertinent to dermatologic disease. d. Record the database acquired on the office or hospital record using the traditional or problem oriented format. 2. Recognize classic historical presentations of primary dermatologic diseases and develop the ability to expand the database by exploring the following: a. risk factors b. exacerbating factors/conditions c. results of personal or medical attempts to treat the condition d. exposure to vocational or avocational skin irritants or common allergens e. use of personal hygiene products f. current or previous UV exposure PHYSICAL EXAMINATION 1. Describe a technique used for and the environment most conducive to performing an examination of the skin. 2. Demonstrate the technique used for palpating the skin, hair and nails and list characteristics to be noted during this examination. 3. Describe the normal and abnormal color characteristics of the skin and list common causes for abnormal findings. 4. List commonly found nevi and describe characteristics that will help identify them. 5. Describe various vascular lesions and list their etiology. 6. List characteristics to observe when examining the skin including the following characteristics of skin, rashes, and/or lesions: a. color b. distribution c. type d. grouping or configuration e. edema f. temperature g. texture 94
  • 95. h. thickness i. mobility & turgor 7. List the most common types of primary skin lesions and describe their appearance. 8. Describe the characteristics to be noted when inspecting and palpating the hair. 9. Describe the common characteristics to be noted when inspecting and palpating the nails. 10. List common normal and abnormal variations in the skin examination found in the newborn and children. 11. List common normal and abnormal variations in the skin examination found in the elderly. 12. List common non malignant skin abnormalities and be able to describe and recognize them. 13. List common cutaneous malignancies and be able to recognize and describe them. 14. List risk factors for Malignant Melanoma and other cutaneous neoplasms. 15. List common nail pathologies and be able to identify them. 16. List common hair pathologies and be able to identify them. DIFFERENTIAL DIAGNOSIS 1. Differentiate between the following common dermatologic conditions: a. intradermal, junctional, hairy, halo, compound, and dysplastic nevi b. purpura, petechiae, spider angioma, and venous stars c. primary lesions such as macule, papule, patch, plaque, wheel, nodule, tumor, vesicle, bullae, & pustule d. secondary lesions such as scale, crust, lichenification, scar, keloid, excoriation, fissure, ulcer, erosion, atrophy 2. When presented with the following conditions develop a differential diagnosis, describe a diagnostic and therapeutic approach a. contact dermatitis b. dermatophyte, viral and bacterial infections of the skin, hair and nails c. infestations d. Lichen Planus e. urticaria f. verrucae g. molluscum contagiosum h. sebaceous cysts i. seborrheic keratosis j. xerosis 3. When presented with a dermatitis differentiate between primary skin conditions and manifestations of systemic disease such as: a. xanthomas b. malar rash of systemic lupus erythematosus c. scarlatina d. erythema infectiosum e. Kaposi’s sarcoma f. septicemia(petechiae, etc) g. nail changes such as clubbing, spooning, Beau’s lines, splinter hemorrhages, etc 4. Although not an exhaustive listing, the NCCPA Blueprint provides sample of the diseases, disorders and medical assessments you may encounter during a dermatological exam: a. Ezematous Eruptions: 95
  • 96. Dermatitis: Atopic, Contact, Diaper, Nummular eczematous, Perioral, Seborrheic, Stasis Dyshidrosis Lichen simplex chronicus b. Papulosquamous Diseases: Dermatophyte infections: Tinea versicolor, Tinea corporis/pedis Drug eruptions Lichen planus Pityriasis rosea Psoriasis c. Desquamation: Stevens-Johnson syndrome Toxic epidermal necrolysis Erythema multiforme d. Vesicular Bullae: Bullous pemphigoid e. Acneiform Lesions: Acne vulgaris Rosacea Folliculitis f. Verrucous Lesions: Seborrheic keratosis Actinic keratosis g. Insects/Parasites: Lice Scabies Spider bites h. Neoplasms: Basal cell carcinoma Melanoma Squamous cell carcinoma i. Hair and Nails: Alopecia areata Androgenetic alopecia Onycomycosis Paronychia j. Viral Diseases: Condyloma acuminatum Exanthems Herpes simplex Molluscum contagiosum Verrucae Varicella-zoster virus infections k. Bacterial Infections: Cellulitis/vasculitis Erysipelas 96
  • 97. l. Other: Acanthosis nigricans Burns Decubitus ulcers/leg ulcers Hidradenitis suppurativa Lipomas/epithelial inclusion cysts Melasma Urticaria Vitiligo DIAGNOSTIC 1. Describe the indications for, complications of, and technique to perform the following procedures a. punch biopsy b. excisional biopsy c. incisional biopsy d. skin scraping 2. Describe the indications for and perform the following diagnostic tests a. KOH prep b. Wood’s light examination c. Transillumination THERAPEUTIC 1. Describe a therapeutic approach to the conditions listed above. 2. Describe the indications, contraindications and adverse reactions for prescribing common topical dermatologic agents. 3. Describe the indications, contraindications, and adverse reactions to common oral agents used to treat dermatologic conditions including, but not limited to, antipruritics, corticosteroids, and antifungal agents. HEALTH PROMOTION AND DISEASE PREVENTION 1. Counsel patients on the importance of protection from UV radiation exposure. 2. Counsel patients on the importance of routine self skin examinations and indications for self referral for dermatologic care. 3. Counsel patients regarding the risk factors and warning signs for skin cancer. COMMUNICATION 1. Be able to communicate in a medically professional manner, both orally and in writing, to the patient, the family and with health care professionals. a. Present to the physician a brief synopsis of the patient’s present illness, pertinent positive and negative findings and the diagnostic and therapeutic regimen instituted. b. Communicate effectively with both patient and family by using a vocabulary familiar to all concerned. c. Counsel patient and family regarding the health problem including an explanation of the disease process, therapy and its rationale, therapeutic options, prognosis and health care services available. 97
  • 98. d. Write routine and all other admission orders by the problem number. e. Write in a SOAP format, clear concise and relevant progress notes including diagnostic, therapeutic and patient education plans. f. Fill out routine laboratory test and diagnostic procedure request forms accurately and with pertinent data. g. Maintain a complete up-to-date problem list. h. Initiate requests for patient services including public health and home nursing, school testing and evaluation and release of medical records. i. Report communicable diseases utilizing appropriate forms and follow-up. j. Write interval notes. k. Perform discharge summaries. l. Give empathetic support to both patient and family in all communications. 2. Understand the roles of the various health care providers in performing primary screening for dermatologic disease. 3. Communicate effectively the breadth and scope of services needed when consulting and/or referring a patient for dermatologic consultation. RESEARCH 1. Demonstrate an awareness of the recognized dermatologic literature, current issues and controversies in the literature and methods for accessing current medical literature while in rural sites. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 98
  • 99. Part III: Specific Clinical Rotation Objectives Elective Rotations: Ears, Nose & Throat The objectives to be attained by the student are as follows: BASIC SCIENCE 1. Describe the anatomic components of the ear, nose, and throat. 2. Describe the physiologic function of the ear, nose and throat. 3. Describe common pathophysiological mechanisms involved in otolaryngology. HISTORY 1. Elicit an appropriate complete history relative to common ENT problems. 2. Record the database acquired on the office or hospital record using a traditional or problem oriented format. 3. Recognize the classic historic presentations of disorders of the ear, nose or throat and further develop the database by exploring risk factors, vocational and avocational factors, and noise exposure. PHYSICAL HISTORY 1. Perform and appropriate physical examination of the ear, nose, and throat. 2. Recognize the multiple organ systems that may be responsible for common ENT complaints. 3. Identify common normal and abnormal findings on physical examination of the ear nose and throat. DIAGNOSTIC 1. Given a patient or historical, physical, and laboratory data, be able to diagnose and initiate treatment or appropriate referral for the following common problems: a. hearing loss b. sinusitis c. foreign body: (ear, nose, and throat) d. otitis externa e. otitis media f. perforated tympanic membrane g. pharyngitis/tonsillitis h. Meniere’s disease i. labyrinthitis j. epistaxis k. rhinitis l. septal deviation m. nasal polyps 2. Know the indications, contraindications, and technique for performing the following: a. audiometry b. tympanograms c. radiologic evaluation including plain films and CT scans 99
  • 100. 3. Although not an exhaustive listing, the NCCPA Blueprint provides sample of the diseases, disorders and medical assessments you may encounter during an ENT exam: a. Eye Disorders: Blepharitis Blowout fracture Cataract Chalazion Conjunctivitis Corneal abrasion Dacryoadenitis Ectropion Entropion Foreign body Glaucoma Hordeolum Hyphema Macular degeneration Orbital cellulitis Pterygium Retinal detachment Retinal vascular occlusion Retinopathy • Diabetic • Hypertensive Strabismus b. Ear Disorders: Acute/chronic otitis media Barotrauma Cerumen impaction Hearing impairment Mastoiditis Meniere's disease Labyrinthitis Otitis externa Tympanic membrane perforation Vertigo c. Nose/Sinus Disorders: Acute/chronic sinusitis Allergic rhinitis Epistaxis Nasal polyps d. Mouth/Throat Disorders: Acute pharyngitis Acute tonsillitis Aphthous ulcers Dental abscess 100
  • 101. Epiglottitis Laryngitis Oral candidiasis Oral herpes simplex Oral leukoplakia Peritonsillar abscess Parotitis Sialadenitis THERAPEUTIC 1. Perform, or assist the physician in performing, the following therapeutic procedures: a. cerumen removal b. sinus lavage c. otic wick insertion 2. Perform or assist in the following procedures developing an awareness of their indications, complications, appropriate equipment, and technique: a. surgical scrub b. donning of gown, gloves and mask c. proper draping of the patient d. proper application of wound dressings e. surgical closure 3. Participate in postoperative care by: a. ordering appropriate IV fluids b. maintaining appropriate IV fluids c. maintaining patient on appropriate diet d. administering wound care with special attention to drains and tubes e. monitoring patients with nasogastric catheters in place f. progressing patient’s ambulation at the appropriate times g. demonstrate measures to prevent post-operative thrombophlebitis/pulmonary emboli 4. List common complications of ENT surgeries and treatments for each complication. 5. Describe the indications and contraindications as well as possible complications for the following surgical cases: a. tonsillectomy and/or adenoidectomy b. myringotomy with or without insertion tubes c. tympanoplasty HEALTH PROMOTION AND DISEASE PREVENTION 1. Counsel patients regarding the following primary preventive measures: a. appropriate use of hearing protection b. smoking cessation as a mechanism to decrease the incidence of respiratory disease and promote healthy living COMMUNICATION 1. Be able to demonstrate both orally in writing a complete database in a concise, orderly fashion. 101
  • 102. 2. Develop an appreciation for the contribution of all health care providers in performing primary screening services for ENT disease and communicate effectively the breadth and scope of services needed when consulting and/or referring a patient for ENT problems. RESEARCH Demonstrate an awareness of the recognized ENT literature, current issues and controversies in the literature and methods for accessing current medical literature while in rural sites. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care. 102
  • 103. Part III: Specific Clinical Rotation Objectives Elective Rotations: Orthopedics The objectives to be attained by the student are as follows: HISTORY 1. Be able to elicit a first or second party history pertinent to care of the orthopedic patient developing skills in data base gathering and competence in common diagnosis. 2. Recognize that musculoskeletal problems rank sixth as a cause for all patient complaints and that 70% of musculoskeletal problems will be cared for by primary care providers and not orthopedists. 3. Recognize the importance of discovering abuse or neglect as the etiology of musculoskeletal injuries during all ages of the lifespan. 4. Discover underlying risk factors for recurrent orthopedic injuries. PHYSICAL EXAMINATION 1. Demonstrate knowledge of muskuloskeletal anatomy, pathology, and physiology applicable to the diagnosis, treatment, and prevention of musculoskeletal disease. 2. Develop proficiency in performing a musculoskeletal examination. 3. Identify abnormal findings on the musculoskeletal examination. 4. Record and/or present orally the data base in a concise, orderly, and accurate fashion. DIAGNOSTIC STUDIES 1. Identify, perform, or and/or interpret appropriate cost effective routine diagnostic procedures based on history and physical examination. 2. Identify the appropriate and available diagnostic studies for a particular problem based on the history and physical examination. 3. Identify and describe the risks, costs, and patient inconvenience of various diagnostic studies. DIFFERENTIAL DIAGNOSIS 1. Based on a given patient’s history, physical examination, or diagnostic studies develop a comprehensive differential diagnosis. 2. When presented with the following symptoms develop a differential diagnosis and diagnostic impression consistent with the data base: a. Back Pain b. Oligo-articular joint pain c. Polyarticular joint pain 3. When presented with a patient exhibiting symptoms consistent with the following disorders develop the ability to differentiate them from conditions that mimic their presentation: a. skeletal fractures/dislocations b. bursitis/tendonitis c. carpal tunnel syndrome d. sprains/strains e. low back pain/sciatica 103
  • 104. f. osteoarthritis g. crystalline arthropathies h. meniscal injuries i. rotator cuff injuries j. Reiter’s syndrome k. Chondromalacia l. Osgood-Slachter’s disease m. Legg-Cathe Perthe’s disease n. multiple myeloma o. scoliosis p. TMJ syndrome q. AC joint separation/dislocation r. Duputyren’s contracture 4. Given an xray film with good exposure and patient positioning identify the following: a. Normal anatomic landmarks b. Fractures c. Dislocations d. Osteoblastic/lytic lesions e. Abnormal calcifications f. Growth deformities g. Osteoarthritic changes 5. Although not an exhaustive listing, the NCCPA Blueprint provides sample of the diseases, disorders and medical assessments you may encounter during an orthopedic exam: a. Disorders of the Shoulder: Fractures/dislocations Rotator cuff disorders Separations Sprain/strain b. Disorders of the Forearm/Wrist/Hand: Fractures/dislocations • Boxer's • Colles' • Gamekeeper's thumb • Humeral • Nursemaid's elbow • Scaphoid Sprains/strains Tenosynovitis • Carpal tunnel syndrome • de Quervain's tenosynovitis • Elbow tendinitis • Epicondylitis c. Disorders of Back/Spine: Ankylosing spondylitis Back strain/sprain Cauda equina 104
  • 105. Herniated nucleus pulposis Kyphosis/scoliosis Low back pain Spinal stenosis d. Disorders of the Hip: Aseptic necrosis Fractures/dislocation Slipped capital femoral epiphysis e. Disorders of the Knee: Bursitis Fractures/dislocations Meniscal injuries Osgood-Schlatter disease Sprains/strains f. Disorders of the Ankle/Foot: Fractures/dislocations Sprains/strains b. Infectious Diseases: Acute/chronic osteomyelitis Septic arthritis j. Neoplastic Disease Bone cysts/tumors Ganglion cysts Osteosarcoma k. Osteoarthritis l. Osteoporosis THERAPEUTICS 1. Identify and initiate treatment for the following classifications of emergent conditions: a. Orthopedic Emergencies 1. infection 2. osteomyelitis 3. septic joints 4. slipped epiphysis 5. acute neurologic deficit b. Urgencies 1. congenital dislocated hip 2. club feet 3. tumors 4. acute bursitis c. Trauma-life saving 1. cardiac and/or respiratory resuscitation 2. bladder trauma 3. bleeding 4. traumatic amputations d. Limb saving 105
  • 106. 1. spine injuries 2. open fractures 3. open dislocations 4. vascular occlusions 5. supracondylar fracture of the humerus in children 6. dislocated knee 7. neurovascular injuries 8. fractures 9. dislocations 2. Develop familiarity with the following techniques, common surgical procedures to include anatomic landmarks and common post-operative care and complications: a. Closed reductions b. Open reductions c. Skeletal traction d. Joint replacements e. Carpal tunnel release/neurolysis f. amputations including AK and BK g. Back surgery procedures to include microsurgery h. bracing i. prosthetic devices j. arthroscopic procedures 3. Perform or assist the following procedures knowing their indications, contraindications, complications, and appropriate equipment and techniques: a. Incision and drainage b. Wound débridement c. Joint aspiration/injection d. Closed management of simple fractures to including casting/splinting e. OR Protocol 1. surgical scrub 2. gowning and gloving 3. prepping the patient 4. proper draping of the patient 5. proper application of wound dressings. f. Lacerations/surgical closure 1. cleansing and débridement of the wound 2. administration of local infiltrative anesthetics including hematoma and regional blocks 3. determine neurovascular involvement 4. suture lacerations 5. administer appropriate tetanus therapy g. Participate in post operative care by: 1. ordering appropriate laboratory and diagnostic tests 2. ordering appropriate IV fluids 3. maintaining patient on correct diet 4. administering wound care with special attention being paid to drains and tubes 5. monitoring patients postoperatively for complications 106
  • 107. 6. progressing the patient’s activity at appropriate times 7. develop knowledge of the appropriate use of anticoagulant therapy 8. implement measures to reduce the risks of post operative embolic phenomena HEALTH PROMOTION AND DISEASE PRVENTION 1. Recognize, develop and implement effective strategies for incorporating health promotion and disease prevention as it relates to the discipline of orthopedics in primary care including: a. Prevention of osteoporosis b. Reducing risk of falls in the geriatric patient c. Prevention of sports related injury COMMUNICATION 1. Be able to communicate in a medically professional manner, both orally and in writing, to the patient, the family, and with health care professionals a. Communicate to the physician a brief synopsis of the patient’s present illness/condition b. Communicate effectively with both the patient and family using a vocabulary familiar to all concerned c. Counsel the patient and family regarding the health problem including an explanation of the disease process, therapy and its rationale, therapeutic options, prognosis, and health care services available d. Write routine and all other admission orders e. Write in a SOAP format, clear concise and relevant progress notes f. Maintain a complete and up to date progress list g. Write interval notes h. Perform discharge summaries i. Give empathetic support to both patient and family in all communications RESEARCH 1. Demonstrate an awareness of the recognized Orthopedic literature, current issues and controversies in the literature and methods of accessing current literature while in rural sites. CULTURAL COMPETENCE 1. Demonstrate an understanding that cultural dimensions of health and illness are essential to effective patient care 107
  • 108. 20. CLINICAL YEAR EVALUATION POLICIES a. General policies: i. It is the student’s responsibility to make sure the preceptor fills out the evaluation and returns it to the program. Evaluations can be filled out online, or done with paper copies and then mailed, faxed, or hand delivered to the program. ii. All anonymous student evaluations and surveys will be administered through a separate Moodle course website. The course site will be maintained by support staff of the PA Program. Faculty will not have access to the evaluations until after final grades have been submitted. For the purpose of course improvement and quality assurance, a mid semester student satisfaction survey will also be administered. At mid-semester only aggregate data will be reported to faculty members (i.e., no statistics, no comments). The aggregate data will be used by the faculty so that general trends can be identified that will help determine changes to be made during the semester that could help with course delivery. Preceptor evaluation of students: Preceptors will evaluate students a minimum of every 5 weeks. b. Types of evaluations (copies can be found in the forms section) i. Preceptor’s Evaluation of the student: 1. For each unique clinical experience, that is 5 weeks in length or longer a Mid-Rotation Evaluation) and a final evaluation needs to be on file for the student. 2. Progress reports (Mid-Rotation Evaluation) are to be filled out biweekly for rotations 5 weeks in length, and monthly for rotations 10 or 15 weeks in length. 3. Final Evaluations must be completed and on file for each unique clinical experience. 4. Multiple preceptors: when there are more than one preceptor at a site, the preceptors can either submit 1 consensus evaluation (one that they all agree upon) or submit individual evaluations and the clinical coordinator will average them. 5. Evaluations can be submitted on-line, as an email attachment, faxed, or sent by US mail. ii. Faculty Evaluations of the student and site 1. A site evaluation will consist of the faculty evaluating the student’s case presentation; the site evaluation, and conducting a preceptor satisfaction survey iii. Student evaluations 108
  • 109. 1. Student satisfaction surveys will be conducted anonymously every 8 weeks. The purpose of the surveys is to evaluate the student’s experience with the clinical year. 2. Students will evaluate the clinical sites. These are not anonymous. The information is not shared verbatim with the clinical preceptor, but general feedback about the site is made available to the site if requested, and also to other students interested in going to that site. 21. CLINICAL YEAR EVALUATION FORMS Preceptor Forms: Mid-Rotation Preceptor Evaluation Form Final Preceptor Evaluation Form Faculty Forms: Mid-Rotation Site Visit Form Evaluation of Case Presentation Student Forms: Site Evaluation 109
  • 110. ISU PA Program Mid-Rotation Evaluation Form Student: Date: Preceptor: Rotation: RATING SCALE DEFINITIONS: Use this rating scale to rate each area independently. Please circle the appropriate number. RATING OF 4 Exhibits no deficits for someone at this point in his/her training. RATING OF 3 Exhibits solid traits, competence, and good potential for success. Any weaknesses present can be corrected easily with additional practice. RATING OF 2 Exhibits clear weaknesses or deficits. These weaknesses would benefit from minor remediation, but are expected to resolve. RATING OF 1 (or below) Exhibits serious weaknesses, deficits, and/or inadequacies. These weaknesses are of major concern. The student should be counseled and put through major remediation as early as possible. COGNITIVE ABILITIES: 4 3 2 1 • fund of knowledge • clinical decision making • patient management MEDICAL INTERVIEW: 4 3 2 1 • ability to ask appropriate questions • elicits pertinent positives/negatives PHYSICAL EXAMINATION: 4 3 2 1 • obtains relevant data • distinguishes between normal/abnormal PRESENTATION SKILLS: 4 3 2 1 • ability to Organize and Synopsize • documentation of the medical record • oral presentation skills PERSONAL CHARACTERISTICS: 4 3 2 1 • professional demeanor • interpersonal skills (with patients & staff) • attendance/punctuality COMMENTS: 110
  • 111. ISU PA PROGRAM FINAL-ROTATION EVALUATION Student: Preceptor: Rotation Number: Date: Type (circle all that apply): Outpatient | Inpatient | ObGyn | Peds | ER | Surg | Psych | Elective Please mark the appropriate box under each heading: ATTENDANCE AND PUNCTUALITY Not Rarely Often Sometimes Rarely Always observed present/ punctual absent/ tardy absent/tardy absent/ tardy present/ punctual       PROFESSIONAL APPEARANCE Not Not appropriate for Generally Generally Usually Always observed the setting appropriate; appropriately, with appropriately, with appropriate unresponsive to a few obvious ex- a few minor suggestions ceptions; responds exceptions to suggestions       INITIATIVE Not Not well Just getting by; Accepts requests, Accepts requests; Exceptional observed motivated; avoids accepts requests generally follows always follows motivation; doing whenever but often fails to through & some- through & fre- exceeds expec- possible follow through times volunteers quently volunteers tations       CHARTS Not Disorganized; Incomplete, poorly Generally accurate, Accurate, complete Concise, relevant observed inaccurate; material organized; reflects complete & well & well organized; & well organized; irrelevant less than adequate organized; requires reflecting good includes subtleties understanding of minor refinement understanding of reflecting a clear patients’ problems & clarity patients’ problems understanding of the case       KNOWLEDGE Not Unable to discuss Fair knowledge of Discusses Can accurately Extensive observed common diseases; has many pathophysiology discuss most knowledge of pathological gaps in for most common common diseases; pathophysiology processes with fundamental diseases; knowledge extends common diseases accuracy concepts limitations in to include a few and other less breadth of uncommon disease common disease knowledge entities states       CLINICAL JUDGMENT Not Decisions and Sound judgment in Errs often but Usually shows Sound logical observed recommendations less than half the usually learns from good judgment thinker; considers often wrong & cases; doesn’t seem mistakes resulting from all factors to reach ineffective to learn from sound evaluation of accurate decisions; mistakes factors contributes in complex cases       111
  • 112. CLINICAL MANAGEMENT Not Contributes Suggests only Sound ideas, but Good judgment; Sound judgment & observed little to patient routine care most needs general less than extensive extensive know- management plan of the time; usually assistance with knowledge base in ledge in clinical fails to follow the clinical clinical management; patient closely management management seldom requires assistance       TEAM PARTICIPATION Not Behavior Very often Often sensitive to Almost always Always considerate observed undermines team insensitive to others; minor sensitive to others; promotes effort others problems with others relations among team members team members       PROFESSIONAL RELATIONSHIPS Not Behavior is Behavior is usually Maintains Establishes Commands observed unacceptable; does acceptable; acceptable & atmosphere of admiration & not cooperate; cooperates when workable mutual respect & respect of others; makes poor necessary; makes relationships dignity with others conducts impression little impression him/herself as a true professional       RELATIONSHIP WITH PATIENTS Not Unable to Fair rapport; Generally good Good rapport; Excellent rapport observed establish often a lack of rapport; occasional listens & with even the most appropriate rapport communication difficulty communicates difficult patients; communicating his/her concern for instills confidence the patients’ in his/her ability problems       HISTORY TAKING Not Unable to elicit an Able to elicit some Generally elicits an Good history Excellent history observed accurate history; pertinent facts accurate history, taking skills; elicits taking skills even cannot elicit the relating to patient’s but some problems an accurate history; with the most pertinent facts symptoms; lacks eliciting all the rarely has a complex patients; surrounding a insight into pertinent facts problem eliciting elicits all pertinent patient’s symptoms/course of all the pertinent facts; exceptional symptoms diseases facts insight into symptoms of diseases       112
  • 113. PERFORMING PHYSICAL EXAMINATIONS Not Does not Performs some Generally Good PE skills; Excellent PE skills even observed perform appropriate PEs performs an usually with the most complex pertinent or PE relating to accurate, performs an patients; elicits all pertinent techniques; patient’s reproducible accurate, findings; exceptional findings are not symptoms; PE, occasional reproducible insight into signs of reproducible; lacks insight problems PE; rarely has a diseases unable to into eliciting or problem recognize signs signs/course of recognizing all eliciting or of disease diseases the pertinent recognizing all physical the pertinent findings findings       UTILIZING DIAGNOSTIC STUDIES Not Lacks basic Appropriately Appropriately Good Excellent observed understanding of performs, performs, understanding of understanding of indications, indications/ utilizes and/or utilizes and indications, contraindications, contraindications, interprets interprets contraindications/ performance, and performance, and some most performance, and interpretation of most interpretation of diagnostic diagnostic interpretation of diagnostic studies common studies studies most diagnostic diagnostic studies studies       FORMULATING DIFFERENTIAL DIAGNOSES Not Lacks ability Able to form Able to Good Excellent complete observed to form partial articulate a complete differential diagnosis with appropriate differential differential differential all essential conditions and differential diagnosis, but diagnosis with with all some less common diseases; misses some most essential essential exceptional insight diagnosis essential conditions, but conditions conditions not quite complete       EMERGENCY MEDICAL KNOWLEDGE, SKILLS, AND ABILITIES Not Lacks the Able to In general, Good level of Performs above level of observed knowledge, respond to responds knowledge, expectation; exceptional skills, or some common appropriately to skills, & insights and abilities; abilities to conditions, but at least 50% of abilities; responds appropriately to respond knowledge, emergent responds 90% of common conditions appropriately to skills, or conditions appropriately to common abilities are encountered at least 75% of situations weak common encountered conditions encountered       113
  • 114. PATIENT EDUCATION, HEALTH PROMOTION, AND DISEASE PREVENTION (PEHPDP) Not Failed to Able to provide Usually able to Good Excellent knowledge, skills, observed demonstrate an some PEHPDP provide knowledge, and abilities in presenting understanding of information; pertinent and skills, and PEHPDP information; basic PEHPDP knowledge, appropriate abilities in exceptional insights knowledge, skills, or PEHPDP presenting skills, or abilities are information to PEHPDP abilities weak patients information in the most cases       EVIDENCE-BASED PRACTICE (EBM) Not Failed to Demonstrates In general, Good Excellent understanding observed demonstrate some demonstrates a understanding and utilization of EBM; any understanding fair and utilization exceptional ability to understanding and utilization understanding of EBM in utilize the current or utilization of of EBM in and utilization patient care; medical literature; evidence-based patient care; of EBM in demonstrated medicine rarely utilized patient care; the ability to exceptional insight (EBM); did not current medical some utilization utilize current seem to utilize literature of current literature medical literature literature demonstrated       CULTURAL COMPETENCY Not Insensitive to Shows some In general Good Excellent sensitivity to observed the various sensitivity to demonstrates demonstration the various cultural, cultural, the various sensitivity to of sensitivity to racial, or other minority racial, or cultural, the various the various patients seen in this other racial, or cultural, racial, cultural, racial, practice; exceptional minority other minority or other or other insights patients seen patients seen minority minority in this in this patients seen patients seen in practice practice; in this this practice minimal practice; no inflexibility or inflexibility or insensitivity insensitivity dealing with noted others       ETHICS Not I have grave Some concerns No concerns observed concerns about about about students’ students’ students’ ethics ethics ethics     114
  • 115. Overall Evaluation Considering all of the above factors, I feel the student’s performance was satisfactory: Strongly Disagree Disagree Agree Strongly Agree     GENERAL COMMENTS Was this evaluation discussed with the student? Yes No Preceptor Printed Name Preceptor Signature Date Phone Number 115
  • 116. MID-ROTATION SITE VISIT FORM Student: Faculty: Date: Rotation: Preceptor: 1. Feedback from preceptor. (Please get mid rotation progress report from student and/or discuss progress with preceptor). 2. Feedback from student. Please fill out the grid below: Question Answer Comments Have you reviewed rotation YES NO objectives with preceptor? Are rotation objectives YES NO being met? Are you maintaining pt. YES NO logs? (review) Are you maintaining YES NO encounter objectives? (review) Are you getting hands on? YES NO Are you formulating YES NO treatment plans? What is your average level 1 2 3 4 of autonomy? Number of patients seen to date for this rotation: Are you doing YES NO documentation? (review) How does the student feel the rotation is going? Does the student have any questions or concerns? Student Patient Presentation 116
  • 117. EVALUATION OF CASE PRESENTATION Student's Name:__________________________ Rotation:____________________________ Observer: ____________________________ Date: __________________________ I. History Patient Identification: Check if Present Age, Sex, Race, Occupation ___ Source Reliability ___ Chief Complaint ___ History of Present Illness Onset Given Properly? Chronologically Coherent? ___ Descriptions Complete and Clear? ___ Past Medical History Childhood Illnesses? ___ Past Hospitalizations? ___ Major Illnesses? ___ Surgeries? ___ GYN/OB? ___ Allergies? ___ Medication History? ___ Includes: Present (Past only if Pertinent) Family History Check if Present Gives Health Status of Parents/Grandparents: __ Health Status of Siblings: ___ Inherited Diseases in Family: ___ Family History of Major Diseases? ___ Social History Occupation: ___ (includes social situation) ___ ETOH: ___ Smoking: ___ Recreational Drugs: ___ 117
  • 118. Review of Systems ____ II. Physical Examination Check if Present Descriptive Statement: Vital Signs: ____ Skin: ____ Lymphatics: ____ HEENT: ____ Pulmonary: ____ Cardio-Vascular: ____ Breast: ____ Abdomen: ____ Rectal/Genital: ____ Musculo-Skeletal: ____ Neurologic: ____ III. Differential Diagnosis • List three or more in order of 1. likelihood 2. •Support these with presenting hx, P.E. findings & outside references 3. IV. Lab Data Yes No Appropriate Test Ordered? ____ Correct Interpretation of Results? ____ Admission Orders (if applicable) ____ Operative Note (if applicable) ____ Post-Op Orders (if applicable) ____ Hospital Course (if applicable) ____ V. Treatment Plan Yes No Includes: Medication? ____ Patient Education? ____ Follow-up Plans? ____ Consultations, Social Services Referral, Community Resource Referrals (CSC) ____ Final Diagnosis and Prognosis ____ 118
  • 119. VI. Question and Answer Period (Oral Case) Superior Above Average Average Unsatisfactory Understands patient's present ____ pathophysiological condition(s) Displays deductive reasoning ____ Able to explain the differential ____ diagnosis a. Rationale for selection ____ b. Rationale for priority ____ Substantiates primary diagnosis ____ VIII. Overall Superior Above Average Average Unsatisfactory Oral/Written Skill ____ Organization ____ Knowledge of the Case (Oral) ____ Knowledge of Related Clinical ____ Medicine Concepts (Oral) Knowledge of Community ____ Agency Resources (CSC) Pertinent Systems Done ____ Completely in P.E. COMMENTS: 119
  • 120. (Please use online version if possible) STUDENT EVALUATION OF ROTATION Student Name: Preceptor: Rotation Site: Rotation Title: Dates of Rotation (month-day-year): ______ to ___________________ INSTRUCTIONS: Please answer all the questions found on this form. We encourage your comments so that the Program can have the best information possible regarding the clinical year . Please do not mark more than one choice. 1. Was there an orientation provided by your preceptor which included discussion of rotation objectives and expectations? Yes No ___ 2. Did your preceptor explain the practical details of his/her practice, i.e. practice style, patient flow, where charts and supplies are found, etc? Yes No ___ 3. Was your preceptor available to provide supervision when needed? Yes No ___ 5 4 3 2 1 Always Sometimes Never Comments: 4. Were you observed by your preceptor doing a history during your rotation? Yes No ___ If yes, how frequently? (Please give an estimated number) If yes, were you given constructive feedback after the observation? Comments: 5. Were you observed doing a complete physical examination during your rotation? Yes No ___ 120
  • 121. If yes, how frequently? (Please give an estimated number) If yes, were you given constructive feedback after the observation? Comments: 6. Were you observed doing parts of a physical examination? Yes No___ If yes, which parts were regularly observed? Comments: 7. Were you instructed in how to perform technical skills? Yes No ___ Comments: 8. Was supervision available when performing technical skills? Yes No___ Comments: 9. Were opportunities provided to perform technical skills after Yes No___ instruction was given? Comments: 10. Were you encouraged to educate the patient regarding his/her Yes No___ health problems, treatment, and follow-up? Comments: 11. Did your preceptor stress preventive care with his/her patients? Yes No___ Comments: 12. After jointly seeing a patient with you, did your preceptor explain the basis for his/her treatment decisions and actions? Yes No___ Comments: 13. Did your preceptor attempt to make difficult concepts easy to 121
  • 122. understand? Yes No ___ Comments: 14. Did your preceptor encourage you in communicating your feedback regarding the rotation experience? Yes No ___ Comments: 15. Were the tasks assigned to you pertinent to your role as you perceive it? Yes No ___ Comments: 16. Were you given the opportunity to explain your differential diagnosis and treatment plan for the patients you examined? Yes No___ Comments: 17. Was your didactic curriculum adequate to prepare you for this rotation? Yes No___ Comments: 18. Did you feel the objectives of the rotation were met? Yes No ___ Comments: 19. Was the staff receptive to your role as a physician assistant? Yes No ___ Comments: 20. Were other health professionals receptive to your role as a physician assistant? Yes No ___ Comments: 21. Were the patients receptive to your role as a physician assistant Yes No ___ Comments: 122
  • 123. 22. Your overall evaluation of this rotation is: Excellent Above Average Average Unsatisfactory Comments: 123
  • 124. 22. APPENDICES Appendix A Guidelines for Ethical Conduct for the Physician Assistant Profession Policy of the American Academy of Physician Assistants adopted May 2000, Amended 2004, 2006, 2007, and 2008 http://www.aapa.org/manual/22-EthicalConduct.pdf Introduction The physician assistant profession has revised its code of ethics several times since the profession began. Although the fundamental principles underlying the ethical care of patients have not changed, the societal framework in which those principles are applied has. Economic pressures of the health care system, social pressures of church and state, technological advances, and changing patient demographics continually transform the landscape in which PAs practice. Previous codes of the profession were brief lists of tenets for PAs to live by in their professional lives. This document departs from that format by attempting to describe ways in which those tenets apply. Each situation is unique. Individual PAs must use their best judgment in a given situation while considering the preferences of the patient and the supervising physician, clinical information, ethical concepts, and legal obligations. Four main bioethical principles broadly guided the development of these guidelines: autonomy, beneficence, nonmaleficence, and justice. Autonomy, strictly speaking, means self-rule. Patients have the right to make autonomous decisions and choices, and physician assistants should respect these decisions and choices. Beneficence means that PAs should act in the patient’s best interest. In certain cases, respecting the patient’s autonomy and acting in their best interests may be difficult to balance. Nonmaleficence means to do no harm, to impose no unnecessary or unacceptable burden upon the patient. Justice means that patients in similar circumstances should receive similar care. Justice also applies to norms for the fair distribution of resources, risks, and costs. Physician assistants are expected to behave both legally and morally. They should know and understand the laws governing their practice. Likewise, they should understand the ethical responsibilities of being a health care professional. Legal requirements and ethical expectations will not always be in agreement. Generally speaking, the law describes minimum standards of acceptable behavior, and ethical principles delineate the highest moral standards of behavior. 124
  • 125. When faced with an ethical dilemma, PAs may find the guidance they need in this document. If not, they may wish to seek guidance elsewhere − possibly from a supervising physician, a hospital ethics committee, an ethicist, trusted colleagues, or other AAPA policies. PAs should seek legal counsel when they are concerned about the potential legal consequences of their decisions. The following sections discuss ethical conduct of PAs in their professional interactions with patients, physicians, colleagues, other health professionals, and the public. The "Statement of Values" within this document defines the fundamental values that the PA profession strives to uphold. These values provide the foundation upon which the guidelines rest. The guidelines were written with the understanding that no document can encompass all actual and potential ethical responsibilities, and PAs should not regard them as comprehensive. Statement of Values of the Physician Assistant Profession • Physician assistants hold as their primary responsibility the health, safety, welfare, and dignity of all human beings. • Physician assistants uphold the tenets of patient autonomy, beneficence, nonmaleficence, and justice. • Physician assistants recognize and promote the value of diversity. • Physician assistants treat equally all persons who seek their care. • Physician assistants hold in confidence the information shared in the course of practicing medicine. • Physician assistants assess their personal capabilities and limitations, striving always to improve their medical practice. • Physician assistants actively seek to expand their knowledge and skills, keeping abreast of advances in medicine. • Physician assistants work with other members of the health care team to provide compassionate and effective care of patients. • Physician assistants use their knowledge and experience to contribute to an improved community. • Physician assistants respect their professional relationship with physicians. • Physician assistants share and expand knowledge within the profession. The PA and Patient PA Role and Responsibilities Physician assistant practice flows out of a unique relationship that involves the PA, the physician, and the patient. The individual patient–PA relationship is based on mutual respect and an agreement to work together regarding medical care. In addition, PAs practice medicine with physician supervision; therefore, the care that a PA provides is an extension of the care of the supervising physician. The patient–PA relationship is also a patient– PA–physician relationship. The principal value of the physician assistant profession is to respect the health, safety, welfare, and dignity of all human beings. This concept is the foundation of the patient–PA relationship. Physician assistants have an ethical obligation to see that each of their patients receives appropriate care. PAs should be sensitive to the beliefs and expectations of the patient. PAs should recognize that each patient is unique and has an ethical right to self-determination. 125
  • 126. Physician assistants are professionally and ethically committed to providing nondiscriminatory care to all patients. While PAs are not expected to ignore their own personal values, scientific or ethical standards, or the law, they should not allow their personal beliefs to restrict patient access to care. A PA has an ethical duty to offer each patient the full range of information on relevant options for their health care. If personal moral, religious, or ethical beliefs prevent a PA from offering the full range of treatments available or care the patient desires, the PA has an ethical duty to refer a patient to another qualified provider. That referral should not restrict a patient’s access to care. PAs are obligated to care for patients in emergency situations and to responsibly transfer patients if they cannot care for them. Physician assistants should always act in the best interests of their patients and as advocates when necessary. Pas should actively resist policies that restrict free exchange of medical information. For example, a PA should not withhold information about treatment options simply because the option is not covered by insurance. PAs should inform patients of financial incentives to limit care, use resources in a fair and efficient way, and avoid arrangements or financial incentives that conflict with the patient’s best interests. The PA and Diversity The physician assistant should respect the culture, values, beliefs, and expectations of the patient. Nondiscrimination Physician assistants should not discriminate against classes or categories of patients in the delivery of needed health care. Such classes and categories include gender, color, creed, race, religion, age, ethnic or national origin, political beliefs, nature of illness, disability, socioeconomic status, physical stature, body size, gender identity, marital status, or sexual orientation. Initiation and Discontinuation of Care In the absence of a preexisting patient–PA relationship, the physician assistant is under no ethical obligation to care for a person unless no other provider is available. A PA is morally bound to provide care in emergency situations and to arrange proper follow-up. PAs should keep in mind that contracts with health insurance plans might define a legal obligation to provide care to certain patients. A physician assistant and supervising physician may discontinue their professional relationship with an established patient as long as proper procedures are followed. The PA and physician should provide the patient with adequate notice, offer to transfer records, and arrange for continuity of care if the patient has an ongoing medical condition. Discontinuation of the professional relationship should be undertaken only after a serious attempt has been made to clarify and understand the expectations and concerns of all involved parties. If the patient decides to terminate the relationship, they are entitled to access appropriate information contained within their medical record. Informed Consent Physician assistants have a duty to protect and foster an individual patient’s free and informed choices. The doctrine of informed consent means that a PA provides adequate information that is comprehendible to a competent patient or patient surrogate. At a minimum, this should include the nature of the medical condition, the objectives of the proposed treatment, treatment options, possible outcomes, and the risks involved. PAs should be committed to the concept of shared 126
  • 127. decision making, which involves assisting patients in making decisions that account for medical, situational, and personal factors. In caring for adolescents, the PA should understand all of the laws and regulations in his or her jurisdiction that are related to the ability of minors to consent to or refuse health care. Adolescents should be encouraged to involve their families in health care decision making. The PA should also understand consent laws pertaining to emancipated or mature minors. (See the section on Confidentiality.) When the person giving consent is a patient’s surrogate, a family member, or other legally authorized representative, the PA should take reasonable care to assure that the decisions made are consistent with the patient’s best interests and personal preferences, if known. If the PA believes the surrogate’s choices do not reflect the patient’s wishes or best interests, the PA should work to resolve the conflict. This may require the use of additional resources, such as an ethics committee. Confidentiality Physician assistants should maintain confidentiality. By maintaining confidentiality, PAs respect patient privacy and help to prevent discrimination based on medical conditions. If patients are confident that their privacy is protected, they are more likely to seek medical care and more likely to discuss their problems candidly. In cases of adolescent patients, family support is important but should be balanced with the patient’s need for confidentiality and the PA’s obligation to respect their emerging autonomy. Adolescents may not be of age to make independent decisions about their health, but providers should respect that they soon will be. To the extent they can, PAs should allow these emerging adults to participate as fully as possible in decisions about their care. It is important that PAs be familiar with and understand the laws and regulations in their jurisdictions that relate to the confidentiality rights of adolescent patients. (See the section on Informed Consent.) Any communication about a patient conducted in a manner that violates confidentiality is unethical. Because written, electronic, and verbal information may be intercepted or overheard, the PA should always be aware of anyone who might be monitoring communication about a patient. PAs should choose methods of storage and transmission of patient information that minimize the likelihood of data becoming available to unauthorized persons or organizations. Computerized record keeping and electronic data transmission present unique challenges that can make the maintenance of patient confidentiality difficult. PAs should advocate for policies and procedures that secure the confidentiality of patient information. The Patient and the Medical Record Physician assistants have an obligation to keep information in the patient’s medical record confidential. Information should be released only with the written permission of the patient or the patient’s legally authorized representative. Specific exceptions to this general rule may exist (e.g., workers compensation, communicable disease, HIV, knife/gunshot wounds, abuse, substance abuse). It is important that a PA be familiar with and understand the laws and regulations in his or her jurisdiction that relate to the release of information. For example, stringent legal restrictions on release of genetic test results and mental health records often exist. 127
  • 128. Both ethically and legally, a patient has certain rights to know the information contained in his or her medical record. While the chart is legally the property of the practice or the institution, the information in the chart is the property of the patient. Most states have laws that provide patients access to their medical records. The PA should know the laws and facilitate patient access to the information. Disclosure A physician assistant should disclose to his or her supervising physician information about errors made in the course of caring for a patient. The supervising physician and PA should disclose the error to the patient if such information is significant to the patient’s interests and well being. Errors do not always constitute improper, negligent, or unethical behavior, but failure to disclose them may. Care of Family Members and Co-workers Treating oneself, co-workers, close friends, family members, or students whom the physician assistant supervises or teaches may be unethical or create conflicts of interest. For example, it might be ethically acceptable to treat one’s own child for a case of otitis media but it probably is not acceptable to treat one’s spouse for depression. PAs should be aware that their judgment might be less than objective in cases involving friends, family members, students, and colleagues and that providing “curbside” care might sway the individual from establishing an ongoing relationship with a provider. If it becomes necessary to treat a family member or close associate, a formal patient- provider relationship should be established, and the PA should consider transferring the patient’s care to another provider as soon as it is practical. If a close associate requests care, the PA may wish to assist by helping them find an appropriate provider. There may be exceptions to this guideline, for example, when a PA runs an employee health center or works in occupational medicine. Even in those situations, the PA should be sure they do not provide informal treatment, but provide appropriate medical care in a formally established patient- provider relationship. Genetic Testing Evaluating the risk of disease and performing diagnostic genetic tests raise significant ethical concerns. Physician assistants should be informed about the benefits and risks of genetic tests. Testing should be undertaken only after proper informed consent is obtained. If PAs order or conduct the tests, they should assure that appropriate pre- and post-test counseling is provided. PAs should be sure that patients understands the potential consequences of undergoing genetic tests – from impact on patients themselves, possible implications for other family members, and potential use of the information by insurance companies or others who might have access to the information. Because of the potential for discrimination by insurers, employers, or others, PAs should be particularly aware of the need for confidentiality concerning genetic test results. Reproductive Decision Making Patients have a right to access the full range of reproductive health care services, including fertility treatments, contraception, sterilization, and abortion. Physician assistants have an ethical obligation to provide balanced and unbiased clinical information about reproductive health care. 128
  • 129. When the PA's personal values conflict with providing full disclosure or providing certain services such as sterilization or abortion, the PA need not become involved in that aspect of the patient's care. By referring the patient to a qualified provider who is willing to discuss and facilitate all treatment options, the PA fulfills their ethical obligation to ensure the patient’s access to all legal options. End of Life Among the ethical principles that are fundamental to providing compassionate care at the end of life, the most essential is recognizing that dying is a personal experience and part of the life cycle. Physician Assistants should provide patients with the opportunity to plan for end of life care. Advance directives, living wills, durable power of attorney, and organ donation should be discussed during routine patient visits. PAs should assure terminally-ill patients that their dignity is a priority and that relief of physical and mental suffering is paramount. PAs should exhibit non-judgmental attitudes and should assure their terminally-ill patients that they will not be abandoned. To the extent possible, patient or surrogate preferences should be honored, using the most appropriate measures consistent with their choices, including alternative and non-traditional treatments. PAs should explain palliative and hospice care and facilitate patient access to those services. End of life care should include assessment and management of psychological, social, and spiritual or religious needs. While respecting patients’ wishes for particular treatments when possible, PAs also must weigh their ethical responsibility, in consultation with supervising physicians, to withhold futile treatments and to help patients understand such medical decisions. PAs should involve the physician in all near-death planning. The PA should only withdraw life support with the supervising physician's agreement and in accordance with the policies of the health care institution. The PA and Individual Professionalism Conflict of Interest Physician assistants should place service to patients before personal material gain and should avoid undue influence on their clinical judgment. Trust can be undermined by even the appearance of improper influence. Examples of excessive or undue influence on clinical judgment can take several forms. These may include financial incentives, pharmaceutical or other industry gifts, and business arrangements involving referrals. Pas should disclose any actual or potential conflict of interest to their patients. Acceptance of gifts, trips, hospitality, or other items is discouraged. Before accepting a gift or financial arrangement, PAs might consider the guidelines of the Royal College of Physicians, “Would I be willing to have this arrangement generally known?” or of the American College of Physicians, “What would the public or my patients think of this arrangement?” Professional Identity Physician assistants should not misrepresent directly or indirectly, their skills, training, professional credentials, or identity. Physician assistants should uphold the dignity of the PA profession and accept its ethical values. 129
  • 130. Competency Physician assistants should commit themselves to providing competent medical care and extend to each patient the full measure of their professional ability as dedicated, empathetic health care providers. PAs should also strive to maintain and increase the quality of their health care knowledge, cultural sensitivity, and cultural competence through individual study and continuing education. Sexual Relationships It is unethical for physician assistants to become sexually involved with patients. It also may be unethical for Pas to become sexually involved with former patients or key third parties. Key third parties are individuals who have influence over the patient. These might include spouses or partners, parents, guardians, or surrogates. Such relationships generally are unethical because of the PA’s position of authority and the inherent imbalance of knowledge, expertise, and status. Issues such as dependence, trust, transference, and inequalities of power may lead to increased vulnerability on the part of the current or former patients or key third parties. Gender Discrimination and Sexual Harassment It is unethical for physician assistants to engage in or condone any form of gender discrimination. Gender discrimination is defined as any behavior, action, or policy that adversely affects an individual or group of individuals due to disparate treatment, disparate impact, or the creation of a hostile or intimidating work or learning environment. It is unethical for PAs to engage in or condone any form of sexual harassment. Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature when: • Such conduct has the purpose or effect of interfering with an individual's work or academic performance or creating an intimidating, hostile or offensive work or academic environment, or • Accepting or rejecting such conduct affects or may be perceived to affect professional decisions concerning an individual, or • Submission to such conduct is made either explicitly or implicitly a term or condition of an individual's training or professional position. The PA and Other Professionals Team Practice Physician assistants should be committed to working collegially with other members of the health care team to assure integrated, well-managed, and effective care of patients. PAs should strive to maintain a spirit of cooperation with other health care professionals, their organizations, and the general public. 130
  • 131. Illegal and Unethical Conduct Physician assistants should not participate in or conceal any activity that will bring discredit or dishonor to the PA profession. They should report illegal or unethical conduct by health care professionals to the appropriate authorities. Impairment Physician assistants have an ethical responsibility to protect patients and the public by identifying and assisting impaired colleagues. “Impaired” means being unable to practice medicine with reasonable skill and safety because of physical or mental illness, loss of motor skills, or excessive use or abuse of drugs and alcohol. PAs should be able to recognize impairment in physician supervisors, PAs, and other health care providers and should seek assistance from appropriate resources to encourage these individuals to obtain treatment. PA–Physician Relationship Supervision should include ongoing communication between the physician and the physician assistant regarding patient care. The PA should consult the supervising physician whenever it will safeguard or advance the welfare of the patient. This includes seeking assistance in situations of conflict with a patient or another health care professional. Complementary and Alternative Medicine When a patient asks about an alternative therapy, the PA has an ethical obligation to gain a basic understanding of the alternative therapy being considered or being used and how the treatment will affect the patient. If the treatment would harm the patient, the PA should work diligently to dissuade the patient from using it, advise other treatment, and perhaps consider transferring the patient to another provider. The PA and the Health Care System Workplace Actions Physician assistants may face difficult personal decisions to withhold medical services when workplace actions (e.g., strikes, sick-outs, slowdowns, etc.) occur. The potential harm to patients should be carefully weighed against the potential improvements to working conditions and, ultimately, patient care that could result. In general, PAs should individually and collectively work to find alternatives to such actions in addressing workplace concerns. PAs as Educators All physician assistants have a responsibility to share knowledge and information with patients, other health professionals, students, and the public. The ethical duty to teach includes effective communication with patients so that they will have the information necessary to participate in their health care and wellness. PAs and Research The most important ethical principle in research is honesty. This includes assuring subjects’ informed consent, following treatment protocols, and accurately reporting findings. Fraud and dishonesty in research should be reported so that the appropriate authorities can take action. 131
  • 132. Physician assistants involved in research must be aware of potential conflicts of interest. The patient's welfare takes precedence over the desired research outcome. Any conflict of interest should be disclosed. In scientific writing, PAs should report information honestly and accurately. Sources of funding for the research must be included in the published reports. Plagiarism is unethical. Incorporating the words of others, either verbatim or by paraphrasing, without appropriate attribution is unethical and may have legal consequences. When submitting a document for publication, any previous publication of any portion of the document must be fully disclosed. PAs as Expert Witnesses The physician assistant expert witness should testify to what he or she believes to be the truth. The PA’s review of medical facts should be thorough, fair, and impartial. The PA expert witness should be fairly compensated for time spent preparing, appearing, and testifying. The PA should not accept a contingency fee based on the outcome of a case in which testimony is given or derive personal, financial, or professional favor in addition to compensation. The PA and Society Lawfulness Physician assistants have the dual duty to respect the law and to work for positive change to laws that will enhance the health and well being of the community. Executions Physician assistants, as health care professionals, should not participate in executions because to do so would violate the ethical principle of beneficence. Access to Care / Resource Allocation Physician assistants have a responsibility to use health care resources in an appropriate and efficient manner so that all patients have access to needed health care. Resource allocation should be based on societal needs and policies, not the circumstances of an individual patient–PA encounter. PAs participating in policy decisions about resource allocation should consider medical need, cost- effectiveness, efficacy, and equitable distribution of benefits and burdens in society. Community Well Being Physician assistants should work for the health, well being, and the best interest of both the patient and the community. Sometimes there is a dynamic moral tension between the well being of the community in general and the individual patient. Conflict between an individual patient’s best interest and the common good is not always easily resolved. In general, PAs should be committed to upholding and enhancing community values, be aware of the needs of the community, and use the knowledge and experience acquired as professionals to contribute to an improved community. Conclusion The American Academy of Physician Assistants recognizes its responsibility to aid the PA profession as it strives to provide high quality, accessible health care. Physician assistants wrote these guidelines for themselves and other physician assistants. The ultimate goal is to honor patients 132
  • 133. and earn their trust while providing the best and most appropriate care possible. At the same time, PAs must understand their personal values and beliefs and recognize the ways in which those values and beliefs can impact the care they provide. 133
  • 134. Appendix B Needle Stick/Bloodborne Pathogen Exposure Policy: i. This policy is to provide guidelines for injuries received during a clinical rotation, including contaminated needle stick or sharp injury; mucous membrane/non-intact skin exposure to blood or blood containing body fluids. ii. NOTE: It is highly recommended that you be seen at the ISU Student Health Center, following exposure, for testing and follow-up. 2. This may facilitate usage of student insurance (assuming you have student insurance) and may dramatically reduce any cost to you. 3. If you do not have student insurance, or are too far away to be seen at the ISU Student Health Center, contact the PA program office before having the tests done. a. The policy of the PA Program is that any costs associated with testing, follow-up care, and medications related to any exposure, are the responsibility of the student. iii. Requirements: 1. Dispose of the needle/sharp in a hard sided container to prevent further injury. 2. Wash the site vigorously with soap and water. For mucous membrane exposure, flush with copious amounts of water. 3. Notify your preceptor and the Program as quickly as possible. 4. Follow the site policy for injury/incident reporting. 5. Follow the site policy for follow-up and treatment of needle stick and/or blood borne exposure. 6. Contact the Human Resource office, or Office Manager to initiate the appropriate paperwork. Payment for any testing may be covered through the State Insurance program. 7. Contact your personal physician. iv. Recommendations: 1. Watch the wound closely for signs of infection. 2. If it has been 5 years or longer since your last tetanus booster, you should receive one now. 3. Get a blood test to assure that you are still protected by Hep B immunization. If your protection is diminished, get a booster at this time. a. If choose not to be vaccinated at this time, repeat the test in 6 months. 4. You should receive a blood test to screen for Hepatitis C antibodies. a. If the test is negative, repeat in 6 months. b. If positive, contact your health care provider. 5. You should receive a baseline test for HIV. a. It should be repeated in 3 months, and 6 months. b. If positive, contact your health care provider. 6. You should obtain and follow current Center for Disease Control virus exposure guidelines. 134
  • 135. Appendix C: Medicare Reimbursement Guidelines for Students 135
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  • 140. Appendix D: Competencies for the Physician Assistant Profession Preamble In 2003, the National Commission on Certification of Physicians Assistants (NCCPA) initiated an effort to define PA competencies in response to similar efforts being conducted within other health care professions and growing demand for accountability and assessment in clinical practice. The following year, representatives from three other national PA organizations, each bringing a unique perspective and valuable insights, joined NCCPA in that effort. Those organizations were the Accreditation Review Commission for Education of the Physician Assistant (ARC-PA), the body that accredits PA educational programs; the Association of Physician Assistant Programs (APAP), the membership association for PA educators and program directors; and the American Academy of Physician Assistants (AAPA), the only national membership association representing all PAs. The resultant document, Competencies for the Physician Assistant Profession, is a foundation from which each of those four organizations, other physician assistant organizations and individual physician assistants themselves can chart a course for advancing the competencies of the PA profession. Introduction The purpose of this document is to communicate to the PA profession and the public a set of competencies that all physician assistants regardless of specialty or setting are expected to acquire and maintain throughout their careers. This document serves as a map for the individual PA, the physician-PA team and organizations that are committed to promoting the development and maintenance of these professional competencies among physician assistants. The clinical role of PAs includes primary and specialty care in medical and surgical practice 1 settings. Professional competencies for physician assistants include the effective and appropriate application of medical knowledge, interpersonal and communication skills, patient care, professionalism, practice-based learning and improvement, systems-based practice, as well as an unwavering commitment to continual learning, professional growth and the physician-PA team, for the benefit of patients and the larger community being served. These competencies are demonstrated within the scope of practice, whether medical or surgical, for each individual physician assistant as that scope is defined by the supervising physician and appropriate to the practice setting. 1 In 1999, the Accreditation Council for Graduation Medical Education (ACGME) endorsed a list of general competencies for medical residents. NCCPA’s Eligibility Committee, with substantial input from representatives of AAPA, APAP and ARC-PA, has modified the ACGME’s list for physician assistant practice, drawing from several other resources, including the work of Drs. Epstein and Hundert; research conducted by AAPA’s EVP/CEO, Dr. Steve Crane; and NCCPA’s own examination content blueprint. 140
  • 141. PHYSICIAN ASSISTANT COMPETENCIES Vers. 3.5 (3/22/05) The PA profession defines the specific knowledge, skills, and attitudes required and provides educational experiences as needed in order for physician assistants to acquire and demonstrate these competencies. MEDICAL KNOWLEDGE Medical knowledge includes an understanding of pathophysiology, patient presentation, differential diagnosis, patient management, surgical principles, health promotion and disease prevention. Physician assistants must demonstrate core knowledge about established and evolving biomedical and clinical sciences and the application of this knowledge to patient care in their area of practice. In addition, physician assistants are expected to demonstrate an investigatory and analytic thinking approach to clinical situations. Physician assistants are expected to: • understand etiologies, risk factors, underlying pathologic process, and epidemiology for medical conditions • identify signs and symptoms of medical conditions • select and interpret appropriate diagnostic or lab studies • manage general medical and surgical conditions to include understanding the indications, contraindications, side effects, interactions and adverse reactions of pharmacologic agents and other relevant treatment modalities • identify the appropriate site of care for presenting conditions, including identifying emergent cases and those requiring referral or admission • identify appropriate interventions for prevention of conditions • identify the appropriate methods to detect conditions in an asymptomatic individual • differentiate between the normal and the abnormal in anatomic, physiological, laboratory findings and other diagnostic data • appropriately use history and physical findings and diagnostic studies to formulate a differential diagnosis • provide appropriate care to patients with chronic conditions INTERPERSONAL & COMMUNICATION SKILLS Interpersonal and communication skills encompass verbal, nonverbal and written exchange of information. Physician assistants must demonstrate interpersonal and communication skills that result in effective information exchange with patients, their patients’ families, physicians, professional associates, and the health care system. Physician assistants are expected to: • create and sustain a therapeutic and ethically sound relationship with patients • use effective listening, nonverbal, explanatory, questioning, and writing skills to elicit and provide information • appropriately adapt communication style and messages to the context of the individual patient interaction • work effectively with physicians and other health care professionals as a member or leader of a health care team or other professional group • apply an understanding of human behavior 141
  • 142. • demonstrate emotional resilience and stability, adaptability, flexibility and tolerance of ambiguity and anxiety • accurately and adequately document and record information regarding the care process for medical, legal, quality and financial purposes PATIENT CARE Patient care includes age-appropriate assessment, evaluation and management. Physician assistants must demonstrate care that is effective, patient-centered, timely, efficient and equitable for the treatment of health problems and the promotion of wellness. Physician assistants are expected to: • work effectively with physicians and other health care professionals to provide patient- centered care • demonstrate caring and respectful behaviors when interacting with patients and their families • gather essential and accurate information about their patients • make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment • develop and carry out patient management plans • counsel and educate patients and their families • competently perform medical and surgical procedures considered essential in the area of practice • provide health care services and education aimed at preventing health problems or maintaining health PROFESSIONALISM Professionalism is the expression of positive values and ideals as care is delivered. Foremost, it involves prioritizing the interests of those being served above one’s own. Physician assistants must know their professional and personal limitations. Professionalism also requires that PAs practice without impairment from substance abuse, cognitive deficiency or mental illness. Physician assistants must demonstrate a high level of responsibility, ethical practice, sensitivity to a diverse patient population and adherence to legal and regulatory requirements. Physician assistants are expected to demonstrate: • understanding of legal and regulatory requirements, as well as the appropriate role of the physician assistant • professional relationships with physician supervisors and other health care providers • respect, compassion, and integrity • responsiveness to the needs of patients and society • accountability to patients, society, and the profession • commitment to excellence and on-going professional development • commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices • sensitivity and responsiveness to patients’ culture, age, gender, and disabilities • self-reflection, critical curiosity and initiative 142
  • 143. PRACTICE-BASED LEARNING AND IMPROVEMENT Practice-based learning and improvement includes the processes through which clinicians engage in critical analysis of their own practice experience, medical literature and other information resources for the purpose of self-improvement. Physician assistants must be able to assess, evaluate and improve their patient care practices. Physician assistants are expected to: • analyze practice experience and perform practice-based improvement activities using a systematic methodology in concert with other members of the health care delivery team • locate, appraise, and integrate evidence from scientific studies related to their patients’ health problems • obtain and apply information about their own population of patients and the larger population from which their patients are drawn • apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness • apply information technology to manage information, access on-line medical information, and support their own education • facilitate the learning of students and/or other health care professionals • recognize and appropriately address gender, cultural, cognitive, emotional and other biases; gaps in medical knowledge; and physical limitations in themselves and others SYSTEMS-BASED PRACTICE Systems-based practice encompasses the societal, organizational and economic environments in which health care is delivered. Physician assistants must demonstrate an awareness of and responsiveness to the larger system of health care to provide patient care that is of optimal value. PAs should work to improve the larger health care system of which their practices are a part. Physician assistants are expected to: • use information technology to support patient care decisions and patient education • effectively interact with different types of medical practice and delivery systems • understand the funding sources and payment systems that provide coverage for patient care • practice cost-effective health care and resource allocation that does not compromise quality of care • advocate for quality patient care and assist patients in dealing with system complexities • partner with supervising physicians, health care managers and other health care providers to assess, coordinate, and improve the delivery of health care and patient outcomes • accept responsibility for promoting a safe environment for patient care and recognizing and correcting systems-based factors that negatively impact patient care • apply medical information and clinical data systems to provide more effective, efficient patient care • use the systems responsible for the appropriate payment of services 143

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