CLINICAL TRAINING IN MEDICINE

Core clinical training of medical undergraduates in General Medicine will consist of clerkships in the different stages in the MBBS programme. 

these include

• Clinical appointments in General (Internal) Medicine prior to the professorial Medicine Appointment (3rd and 4th Year appointments)
• Clinical clerkships in identified finer specialties related to Medicine (Short Appointments- these will be conducted in parallel with the 3rd and 4th year Appointments prior to the professorial appointment)
• Professorial Medicine Appointment (i.e. Final or 5th year appointments)

 

Clinical appointments in General (Internal) Medicine prior to the Professorial Medicine Appointment (3rd and 4th Year appointments)

These are clinical training in General (Internal) Medicine before the commencement of the Professorial Medicine appointment. The main components in this training should include

• An introductory programme in Medicine for a minimum of one-week duration
• A minimum of two clinical appointments in General Medicine
• Each would be 6-8 weeks duration. 

 

Learning Objectives: Introductory Medicine Appointment 

On completion of the programme the student should be able 

1. observe appropriate student-patient relationship and proper ethical conduct showing kindness, care and concern to patients.
2. learn the basics of communication skills relevant to patient and illness.
3. be able to list the items of a complete history and record the symptoms of each system in a systematic manner.
4. be able to describe the basis of physical examination techniques from the knowledge of basic sciences. 

Learning Objectives: 3^rd Year Appointment in General (Internal) Medicine  

After completing the first appointment in General (Internal) Medicine the student should be able to:

1. Understand the functioning of the ward unit, outpatient clinics, referral system and the different roles played by the members of the health care team. 
2. Interview and obtain a comprehensive and accurate history, which should include the following components:
   1. Defining the presenting and subsidiary complaints and their duration
   2. History of present illness in a chronological manner
   3. Past history of illnesses and surgeries
   4. Drug and allergy history
   5. Gynaecological and obstetric history (where relevant)
   6. Family history, personal, social and occupational history 
   7. Ask relevant questions when exploring symptoms related to presenting compliant(s) and different systems (system review)
3. Perform a physical examination – general and systems examination.
4. Analyze the clinical features using pathophysiological mechanisms and arrive at a differential diagnosis. 
5. Understand the anatomical, biochemical and pathophysiological basis of symptoms, signs and the results of basic investigative procedures that have been carried out. 
6. Identify and describe the investigations carried out on their patients.
7. State with reasons the management of patients under your care 
8. Describe the procedures done in the ward and be able to perform selected procedures under supervision.
9. Describe how common medical emergencies are managed.
10. Demonstrate empathy and maintain high ethical standards. 
11. Develop a good student patient relationship, communicate effectively, understand the psychological and social factors such as beliefs, fears and anxieties patients undergo during illness. 
12. Identify the components recorded in a case history during the ward stay, at discharge and in the clinics.

As a student, meet as many patients as possible during your first appointment. You should attempt to speak to them and listen to their life stories, „take histories‟ and examine as many as possible. Learning from the patients as to how the symptoms developed, understanding the perception of symptoms are subjective and unique to each individual, examining the patients for abnormal physical signs that indicate the effects or complications of diseases, and studying the pathogenesis of their disease state. Studying around the problems your patient has is the best way to learn the subject of Medicine! 

Pay special attention to patients having the following common conditions. Patients having these diseases or conditions are commonly encountered in the wards. We have categorized them to the organ-systems. Make it a point to read about these conditions from the recommended textbooks in Medicine.

 

Learning Objectives: 4^th Year Appointment in General (Internal) Medicine

In 4^th year medical appointment student should be able to

1. Explain the pathophysiological basis of the common diseases and their investigation and management process.
2. Interview and obtain a comprehensive and accurate history.
3. Preform a relevant physical examination and elicit physical signs. 
4. Analyze the clinical information and arrive at a reasonable clinical differential diagnosis, 
5. Plan appropriate investigations to arrive at a clinical diagnosis, while considering their utility, efficacy and costs.   
6. Describe with reasons the management carried out on patients and be able to develop individualized care plan.
7. Understand the impact of socio-cultural factors on the illness and the effect of the illness on the patient and family and appreciate relevant ethical issues. 
8. Demonstrate empathy and high maintain high ethical standards.
9. Communicate well with patients from different social and cultural backgrounds and with their families with particular reference to giving information, obtaining consent and breaking serious news. 
10. Write case notes, daily status, referrals, discharge summaries, notification procedures, clinic notes and prescriptions. document 
11. Work as a member of a health care team caring for patient as a part of the health care team while understanding of the limitations as a medical student.
12. Know the support provided by the health system, the social service sector and informal carers towards provision of care for patients in hospital and in the community.   

Medical undergraduates will maintain a portfolio/ logbook provided by the Department of Medicine during the pre-professorial appointments. The students will also make home visits to learn the issues related to patient care in the home environment.

Basic concepts in history taking in medicine and correct techniques in physical examination should be the main learning outcomes during the first appointment in general medicine. The second and subsequent appointments in general medicine should focus on identification and making a problem list and management of patients with common medical conditions.

 

Learning Objectives: Professorial Medicine Appointment 

The professorial appointment in Medicine should consist of minimum duration of 8 weeks continuous training during the 5^th year. 

Learning objectives for the Professorial Medicine Appointment 

On completion of the Professorial Medicine Appointment the student should be able to 

1. Work in a responsible manner for the wellbeing of the patient assigned to him/her and work independently as a house officer under supervision.
2. Interview and obtain comprehensive histories, perform a systematic physical examination and elicit physical signs. 
3. Analyze the clinical information competent to state and arrive at a reasonable clinical differential diagnosis,
4. Plan for investigating the patient, interpret routine laboratory tests, radiological, electrocardiography and other tests
5. Describe common diseases, their pathophysiological basis, clinical presentations, treatment and prognosis.
6. Describe an appropriate plan of management plan and reason out the basis for them
7. State indications, limitations, patient preparation, consenting process and undesirable effects of common diagnostic and therapeutic procedures
8. Work as a part of the team managing medical emergencies commonly seen in medical wards and emergency medical unit 
9. Demonstrate empathy and high maintain high ethical standards
10. Communicate well with patients from different social and cultural backgrounds and with their families with particular reference to giving information, obtaining consent and breaking serious news 
11. Write case notes, daily status, referrals, discharge summaries, clinic notes and prescriptions. document 
12. Know the support provided by the health system, the social service sector and informal carers towards provision of care for patients in hospital and in the community  

Students will maintain a workbook or portfolio during the appointment to document the different leaning activities and clinical exposure they received during the period of clerkship. During the Professorial Appointment students will undergo a minimum of 2 days of working as a shadow house officer.

 

Learning Outcomes for Finer Specialties 

Learning Outcomes in Cardiology 

At the end of the appointment students should be able to 

1. Describe the anatomy and physiology of the cardiovascular system, pathogenesis of its disorders and scientific basis of their management.
2. Obtain histories, elicit physical signs and interpret physical signs, arrive at a clinical diagnosis, describe pathophysiology, principles of management (including prevention) and prognosis of patients having the following conditions.
   1. Acute coronary syndrome
   2. Acute and chronic heart failure 
   3. Cardiogenic shock
   4. Common arrhythmias
   5. Pulmonary embolism
   6. Valvular heart disease
   7. Congenital heart disease
   8. Hypertension
   9. Infective endocarditis
   10. Myocarditis, pericardial diseases and cardiomyopathy
   11. Rheumatic heart disease
   12. Risk factors and determinants of cardiovascular disorders
3. Describe the indications, limitations necessary preparations and be able to interpret the basic findings of the following investigations. 
   1. ECG
   2. Chest radiograph
   3. Echocardiography 
   4. Trans esophageal echocardiography
   5. Stress ECG
   6. Holter monitoring
   7. Coronary angiography
4. Identify the indications and describe the necessary preparations of the following procedures.
   1. DC cardioversion 
   2. Insertion of a temporary pacemaker
5. Describe an appropriate plan of management for patients having cardiovascular disorders and the emergency management of the following conditions.
   1. Acute coronary syndromes (with introduction to thrombolytic therapy, heparinization, intravenous nitrates and primary revascularization)
   2. Acute left ventricular failure
   3. Cardiogenic shock
   4. Cardiac arrest and resuscitation (with emphasis on guidelines for resuscitation & defibrillation)
   5. Heart block (with introduction to pacing)
   6. Tachyarrhythmia (monitoring and cardioversion)
6. Communicate effectively with patients from different social and cultural backgrounds and with their families with particular reference to obtaining consent and giving information in relation to,
   1. The nature of illness risk factor modification
   2. Medication used and the side effects
   3. Therapeutic options including surgical options
   4. The prognosis
7. Communicating breaking serious news to patients or relatives in relation to cardiovascular disorders: cardiac arrest, intractable heart failure, agonal rhythm
8. Write case notes, daily status, referrals, discharge summaries, clinic notes and prescriptions. 
9. Demonstrate empathy and kindness.
10. Be an effective member of the healthcare team and know the health facilities and social support available to care for cardiac diseases in Sri Lanka. 
11. Recognize key ethical issues and help to resolve them. 
12. Play an advocacy role in preventing cardiovascular disorders

 

Learning Outcomes in Chest Medicine

At the end of the appointment students should be able to

1. Describe the anatomy and physiology of the respiratory system, pathogenesis of its disorders and scientific basis of their management. 
2. Obtain histories, elicit physical signs and interpret physical signs, describe pathophysiology, principles of management and prognosis of patients having the following conditions.
   1. Bronchial Asthma 
   2. Chronic Obstructive Pulmonary/ Airways Disease (COPD/ COAD)
   3. Pneumonia- typical and atypical 
   4. Tuberculosis 
   5. Bronchiectasis
   6. Lung abscess 
   7. Tumors of the Respiratory System
   8. Interstitial Lung Diseases (ILD) including Idiopathic Pulmonary Fibrosis (IPF)  
   9. Pneumothorax
   10. Co-pulmonale
   11. Pleural effusion
   12. Obstructive Sleep Apnea (OSA) 
3. Arrive at a clinical diagnosis of disorders of the respiratory system.
4. Understand the basis of Oxygen therapy and be able to select the appropriate source, interphase and targets in a critically ill patient and a patient on long term oxygen therapy (LTOT)
5. Describe the indications, limitations and be able to interpret findings of investigations that are relevant:  
   1. Arterial blood gas (ABG)
   2. Pleural fluid 
   3. Lung function tests (spirometry and diffusion studies) and peak expiratory flow rates (PEFR)
6. Describe the anatomical-radiological correlation on the chest radiograph, interpret the abnormalities seen in common respiratory conditions on the chest radiograph and describe the uses of special studies such as CT scan and Ultrasound scan of the chest
7. Explain the principles of advanced investigation techniques in respiratory medicine such as fiber optic Bronchoscopy (FOB) , fiber optic Thoracoscopy, Non Invasive Ventilation(NIV)  and understand the indications, patient preparation, procedure and interpretation of findings. 
8. Identify the indications, describe the necessary preparations and perform supervision the following procedures under supervision,
   1. Direct smear examination of the sputum (collection and ZN stain)
   2. Mantoux test
   3. Technique of use of different inhalers in asthma and COPD
   4. Using a nebulizer 
   5. Pleural aspiration 
   6. Lung function test (spirometry and using the peak flow meter) 
   7. Management of a Inter Costal tube 
   8. Chest physiotherapy for COPD and bronchiectasis
   9. Non-Invasive Ventilation
   10. High Flow Oxygen Therapy
   11. Pulmonary Rehabilitation
9. Describe the principles of diagnosis prevention and treatment strategies of tuberculosis of Sri Lanka including Directly Observed Treatment, screening, follow-up, contact tracing, management of complications and multi drug resistant TB (tuberculosis)
10. Describe the emergency and where relevant intensive care management of following conditions,
    1. Acute severe asthma
    2. Acute exacerbation of COPD
    3. Pneumothorax
    4. Massive haemoptysis
    5. Respiratory failure
11. Communicate effectively with patients from different social and cultural backgrounds and with their families with particular reference to giving information on
    1. Inhaler medication
    2. Using the peak flow meter
    3. Pulmonary tuberculosis with regards to treatment and prevention
    4. Chronic Asthma 
    5. COPD
    6. Indoor and outdoor air pollution including occupational exposure 
12. Communicate effectively with patients from different social and cultural backgrounds and with their families with particular reference to giving information and breaking serious news in relation to 
    1. Terminal respiratory failure
    2. Advanced lung malignancies
    3. Advanced fibrosis 
    4. Multi-drug resistant TB 
    5. COVID related illness
    6. Prognosis of common disorders
13. Write case notes, daily status, referrals, discharge summaries, clinic notes and prescriptions. 
14. Demonstrate empathy and maintain high ethical standards
15. Be an effective member of the healthcare team and know the health facilities and social support available to care for respiratory diseases in Sri Lanka. 

 

Learning Outcomes in Neurology 

At the end of the appointment students should be able to 

1. Describe the anatomy and physiology of the neurological system, pathogenesis of its disorders and scientific basis of their management.
2. Obtain histories, elicit physical signs and interpret physical signs, describe pathophysiology, principles of management and prognosis of patients having the following conditions.
   1. Stroke, 
   2. Epilepsy, 
   3. Myasthenia gravis and other neuro-muscular junction disorders
   4. AIDP, CIDP, 
   5. Peripheral neuropathies
   6. Myopathies,
   7. Parkinson disease and other movement disorders, 
   8. CNS infections (Meningitis, encephalitis, cerebral malaria, cerebral abscess, TB)
   9. Cervical and lumbar root lesions, 
   10. Spinal cord compressions and other spinal cord diseases 
   11. Demyelinating and autoimmune neurological disorders
3. Arrive at a clinical diagnosis of common and important disorders of the neurological system
4. Describe and outline  
   1. Differential diagnosis of speech disorders and localizing the site of the lesion identification of common gait disorders
   2. Different involuntary movements, their identification and the management of Parkinson's disease
   3. The management of myasthenia Gravis, Motor Neuron Disease and Syringomyelia 
5. Identify the indications, describe the necessary preparations and perform under supervision a lumbar puncture in a model
6. Describe the indications, limitations, underlying principles and be able to interpret findings of investigations that are relevant 
   1. Lumbar puncture
   2. CSF manometry
   3. Nerve conduction studies 
   4. EMG
   5. EEG
   6. CT scanning and MRI scanning.
7. Describe the neuro-radiological correlations and recognize typical patterns of common abnormalities on plain radiograph, CT & MRI scans of the head and spine, carotid angiogram and myelogram
8. Describe the emergency management of following conditions
   1. Unconscious patient
   2. Fits and status epilepticus
   3. Respiratory muscle paralysis’
   4. Increased infra-cranial pressure
9. Describe the management of acute stroke including procedures, indications and contra indications for thrombolytic therapy. Be able to asses disability after stroke and understand the relevant components of stroke rehabilitation. 
10. Communicate effectively with patients from different social and cultural backgrounds and with their families with particular reference to obtaining consent and giving information in relation to common neurological disorders and communicating serious news to patients or relatives in relation to neurological disorders: brain death, vegetative states, massive stroke, advanced stages of neuro-degenerative diseases, Motor Neuron Disease.
11. Write case notes, daily status, referrals, discharge summaries, clinic notes and prescriptions. 
12. Demonstrate empathy and high maintain high ethical standards
13. Be an effective member of the healthcare team and know the health facilities and social support available to care for neurological disorders in Sri Lanka.

 

Learning Outcomes in Rheumatology 

 At the end of the appointment students should be able to 

1. describe the anatomy and physiology of the joints and musculoskeletal system, pathogenesis of its disorders and scientific basis of their management 
2. obtain histories, elicit physical signs and interpret physical signs, describe pathophysiology, principles of management and prognosis of patients having the following conditions:
   1. Rheumatoid     arthritis
   2. Osteoarthritis
   3. SLE
   4. Polymyositis
   5. Scleroderma 
   6. Spondyloarthritis
   7. Soft-tissue rheumatism 
3. examine the following components of the locomotor system
   1. cervical spine
   2. lumbar spine
   3. hands
   4. knee joint 
4. perform a detailed clinical evaluation of a patient presenting with 
   1. reginal pain syndrome with emphasis to pain in the neck
   2. lower backache
   3. pain in the shoulder region
   4. pain in the knee
5. arrive at a clinical diagnosis of disorders of the musculoskeletal system 
6. describe the indications, limitations and be able to interpret findings of investigations that are relevant:
   1. immunological investigations in rheumatological conditions 
   2. radiological investigation of the hands, spine, knees, feet and pelvis and hip joints
7. plan the investigations and the short- and long-term management of patients, including   the   pharmacological   and   non- pharmacological     therapies      in common rheumatological disorders 
8. communicate the prognosis of rheumatological disorders, obtain consent for investigations and treatment, and explain the indications and side effects of the following groups of drugs:
   1. Simple analgesics
   2. Non-steroidal anti-inflammatory drugs (NSAID)
   3. Disease- modifying antirheumatic drugs (DMARDs)
   4. Corticosteroids
   5. Immunosuppressants
   6. Biologics – brief idea would suffice
9. asses the needs and describe the value   of   physiotherapy, occupational   therapy, speech   therapy   in rehabilitation in patients with rheumatological, neurological and orthopedic patients
10. write case notes, daily status, referrals, discharge summaries, clinic notes and prescriptions. document 
11. demonstrate empathy and  maintain high ethical standards
12. be an effective member of the multi-disciplinary healthcare team and know the facilities and social support available for patients with long term disability in Sri Lanka

Learning Outcomes in Emergency Medicine 

At the end of the appointment students should be able to

1. Correctly assess, identify medical emergencies, obtain a focused history and examine rapidly (verbal and non-verbal) relevant to patient presentation and arrive at a diagnosis or a differential diagnosis. 
2. Obtain histories, elicit physical signs and interpret physical signs, describe pathophysiology, principles of management and prognosis of patients having the following conditions in medical emergencies. 
   1. Acute shortness of breath 
   2. Acute chest pain 
   3. Acute severe headache 
   4. Acute states of confusion 
   5. Sudden loss of consciousness 
   6. Uncontrolled convulsions 
   7. Sudden onset neurological deficit 
   8. Acute poisoning
   9. Snake bite
   10. Shock (Cardiogenic, hypovolemic, anaphylactic, septic and neurogenic) 
   11. Cardiac arrest 
   12. Anaphylaxis 
   13. Endocrine and metabolic emergencies 
3. Organize information gathered from the interview, physical examination, and diagnostic tests and formulate reasonable hypotheses and differential diagnoses appropriate to the acute care setting 
4. Identify the indications, describe the necessary preparations and perform under supervision the following procedures 
   1. Arterial puncture for blood gas analysis
   2. Carotid massage 
   3. Basic and advanced life support 
   4. Cardioversion 
   5. Assisted ventilation/ airway skills (Bag mask ventilation, endotracheal intubation) 
5. Obtain consent for investigations and treatment and communicate the prognosis of common emergencies.
6. Write case notes, daily status, referrals, discharge summaries, clinic notes and prescriptions.
7. Demonstrate empathy and maintain high ethical standards 
8. Be an effective member of the healthcare team and know the health facilities and social support available to care for medical emergencies in Sri Lanka.

Appointments in identified finer specialties related to Medicine - (Short appointments) 

The main objective of these appointments is to provide clinical exposure in finer specialties related to General Medicine which cannot be adequately provided or covered in a General medical  ward.  This  training  will  be  done  during  these  short  appointments  with  relevant specialists.

The following finer specialties have been identified. They have been classified as essential and preferable. In the event that a relevant specialist is not available or an appointment cannot be accommodated due to time constraints, the needed training will be provided during the course of a General Medicine appointment.

Essential short appalments	Other short appointments
Dermatology	Gastroenterology
Sexually Transmitted Disease	Endocrine and Diabetes
Chest medicine	Medical Oncology
Rheumatology and Rehabilitation	Emergency Medicine
Nephrology	Geriatric Medicine
Neurology	Palliative Medicine
Cardiology	Radiology

Appointments in finer specialties will be conducted after completion of the 3rd Year Appointment in General (Internal) Medicine. There will be a minimum exposure of 1 week in each essential finer specialty. All finer specialty appointments must have clearly formulated learning objectives. (See section 5). These objectives were developed by each respective faculty and given to students and trainers.The use of workbooks / portfolio / logbooks for all appointments will be encouraged.Haematology and Transfusion Medicine – will be covered during General Pathology and General Medicine Appointments.The Family Medicine programme will be organized by the Department of Community Medicine and Primary Care.

 

ASSESSMENTS

Marking scheme in Medicine

Marking scheme for the different assessments in Medicine in the MBBS programme is as follows.

1. Multiple Choice Questions (MCQ) paper – 20 marks
2. Structured Essay Question (SEQ) paper -20 marks
3. Short case assessments – 20 marks
4. Long case assessments – 20 marks
5. Continuous assessments – 20 marks

 

Multiple Choice Question (MCQ paper)

The common MCQ examination conducted at present will be continued with the same format (30 single best answer questions and 20 true/ false type questions). The number of questions in each system / section e.g. cardiovascular system, respiratory system in the common MCQ paper is given in the annexure.

 

Structured Essay Question (SEQ) Paper

The duration of this paper will be 3 hours. There will be 5 SEQs of three hours duration. The questions included in the SEQ paper will be formatted to assess the following main domains. 

1. Interpretation of clinical and / or laboratory findings 
2. Knowledge on the management of medical emergencies
3. Pathophysiology
4. Comprehensive management including ethical issues where relevant therapeutics
5. Epidemiology
6. Prevention

 

Short Cases 

This part of the examination will consist of a minimum of 4 cases representing the major systems, namely cardiovascular system, respiratory system, nervous system and abdomen. The duration of each case will be 7.5 minutes.  5 minutes are allocated for the examination and 2.5 minutes are allocated for the discussion.

Candidates will be given specific instructions at each station. Specific instructions will be displayed at each of the short case station (e.g., Examine this patient’s cardiovascular system). The duration of each case will be 7.5 minutes.  Each student will examine a patient for 5 minutes at a particular station and be interviewed by two examiners for 2.5 minutes. A structured examination sheet will be used to ensure a uniform marking scheme. 

 

Long Case 

Students will be allocated 40 minutes to obtain a detailed history and physical examination and formulate a management plan. This will be followed by a 20-minute discussion with a panel of two examiners. A structured examination sheet will be used to ensure a uniform marking scheme.

Presentation should include a complete history, differential diagnosis based on the history and physical examination findings. A uniform method of presenting the findings will be encouraged. Presenting summaries of the case and problem lists at the very beginning will be not be required. Urine testing will not be done, and instead a report of a test will be made available for the student. 

Long cases should preferably have multiple problems and physical signs. Long cases assessments based only on the history should be avoided as long cases given to candidates

 

Cotinuous assessments

Formative Assessments

• During the Clinical Appointments (eg. Mini Clinical Evaluation Exercise) 
• Assessment of group presentations of the home visits

 

Continuous (In Course) Assessments 

Assessments at the end of the 4^th Year     

Interview Based Portfolio/ Work Book Assessment  

• 15 cases each from 1st and 2nd Clinical Medicine Appointments
• 3-5 cases from each short appointment 

10 Marks will be allocated to an assessment of case scenarios based on work books. This will be conducted by the academic staff members of the Department with the assistance of other staff from the Ministry of Health and Faculty.

 

Assessments during and at the end of the Professorial Appointment     

• Assessment of performance of ward work, based on cases allocated to individual students. This will include history-taking skills, physical examination skills, clinical reasoning, formulating comprehensive plan of management, patient welfare, and knowledge related to the illness etc.) 
• Assessment of Communication Skills
• Structured oral examination focusing on emergencies and ethics. 
• Objective Structure Clinical Examination 

10 marks will be allocated for continuous assessments for Medicine during the Prof Appointment which will be conducted during or at the end of the Professorial appointment.