FCH 251 (LU 6) blueprints Department of Family and Community Medicine College of Medicine-Philippine General Hospital UP Manila

Foreword The Family and Community Medicine Learning Unit 6 (LU 6) rotation is subdivided into three sub rotations: a two week Supportive, Palliative and Hospice Care (SHPM) rotation, one week Community Medicine rotation and one week for the Ambulatory Care unit rotation. Each of which has its own instructional design which will be presented individually in this report.

Supportive, Hospice and Palliative Medicine (SHPM) Rotation

Course Description: This is a two week rotation which will focus on clinical practice in the provision of Palliative and Hospice Care to patients and their families in the hospital and home care setting. Must have satisfactorily passed LUC 5 SHPM ambulatory clinic (3rd floor OPD bldg), Hospice unit at Cancer Institute, Child-Family Supportive Care Program at the UP-PGH Cancer Institute and Community Home visits To provide exposure and training in the care of terminally/chronically ill patients and their families in the context of primary health care

Pre-requisites: Setting of Learning Experience:

General Objective:

LEARNING OBJECTIVES Given an actual patient, a student under supervision is expected to demonstrate the following competencies: Apply the principles of Hospice and Palliative Care in the management of chronically and terminally ill patients.

CONTENT Hospice and Palliative Care: the history and concept Review of: Trajectory of illness Impact of illness

LEARNING ACTIVITIES Attend orientation Random interview with hospice personnel Small group discussion Independent reading

EVALUATION Attendance Global rating scale for direct observation Consultant/Resident evaluation Reflection paper Chart review

RESOURCES Reference c/o hospice library , venue, schedule, resource persons, wards

Specific objectives 1. Perform adequate assessment of terminally ill patients and their families

Pre-exposure activities History taking Bedside demonstration Health beliefs Actual patient exposure Family assessment tools APGAR Genogram SCREEM Physical examination in the context of terminal/chronic illness Biomedical/Biopsychosocial Assessment
Rounds with resident in charge and fellow in charge

Patient feedback End of rotation examination Lecture notes from OSI I (family assessment tools)

Independent reading (review of previous lectures/readings OSI I)

2. Prioritize and manage common conditions identified. Clinical Pain control Symptom control Nutrition Immobilization

Basic pathophysiology Basic principles in the management of chronically and terminally ill patients Principles of drug use Symptom management in palliative care Evidenced based medicine

Direct observation Bedside demonstration Actual patient exposure Independent learning

Self and peer evaluation Patient feedback

Psychosocial Caregiver fatigue Depression Co-dependence Collusion Dealing with difficult patient/relatives

Basic communication skills Active listening skills Counseling Family meeting Ethics in palliative care Legal medicine

Demonstration Clip showing Role-play Lectures Bedside rounds

Formative evaluation

Demo tapes TV. VHS LCD Laptop Facilitator(s)

3. Identify the indications for admission to: hospice unit at the cancer institute home visit /home care

Guidelines for admission at the hospice unit/home visit

Orientation Small group discussion Independent learning

Formative evaluation using students reflection paper Examination

Handouts

program 4. Refer patients to the proper specialty /services Referral forms Indication for referral Health linkages/networking with other hospices, Madre de Amor and Bulacan Hospice Coordinating/Communicating with other subspecialty in the care of patient Data recording Record keeping Quality assurance

Bedside rounds Preparation and follow up of referrals Chart review Progress notes Feedback from Specialties/services

Home visit to madre de amor and bulacan hospice

5. Maintain complete, legible and updated patient records

Update chart entries

Chart review Progress notes

Patient charts

6. Provide instructions prior to discharge or transfer of patients

Transfer of care Communication skills Home instructions

Preparation of clinical abstract and discharge summaries Patient and caregiver

Feedback from patient and caregiver Direct observation using checklist or Rating scale

Patient charts

training Discharge PE Actual patient exposure Patient/caregiving Instruction Networking 7. Perform common tasks/procedures both for admitted patients and home care Basic procedures IV insertion Administering oxygen Administering common medicines: oral, IM, SC Nebulization NGT insertion Foley catheter insertion Nutrition planning Blood extraction Bedsore/colostomy /tracheostomy care Family meetings Demo and return demo home visit with hospice team Actual patient exposure Independent learning Self and peer evaluation Rating scale Checklist Video tapes Dummies for demo purposes Skills laboratory Patient charts

8. Communicate effectively with other hospice team members

Giving and receiving feedback Active listening skills

Role-play Carry out tasks Small group discussion

Self and peer evaluation Formative feedback Direct Observation using rating scale

Preceptors Feedback forms

9. Provide end-of-life care and comfort to terminally ill patients and their families

End of life care Active listening skills Counseling skills Bereavement care

Case discussions Family meetings Bedside rounds Actual patient exposure Independent learning Debriefing

Patient/family feedback Self and peer evaluation Student logbook/diary/Census

Student logbooks Patient/client feedback forms Conference rooms Preceptors

Medical ethics Religion and philosophy

List of must knows and nice to know topics:

Hospice and Palliative Care principles Adequate assessment of terminally ill patients

Common signs and symptoms seen in terminally ill patients and basic management Communication (breaking bad news, counseling skills) Medicines commonly used in hospice (Morphine myths and fallacies) End of Life care Medical Ethics

Class schedule/blueprint of activities: 1st week Monday A.M. General Orientation of the LU6 course

Tuesday A.M. Orientation with fellow of the month with consultant Students hour Case Management Meeting (9am 10:30)

Wednesday A.M. Palliative Care team meeting

Thursday A.M. DFCM Staff conference

Friday A.M. Palliative Care team meeting

SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. SHPM patient care and tasks (Ward rounds/OPD at CI 108)

SHPM patient care and tasks (Ward rounds/OPD)

SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. Junior Journal Club (student evidence based presentation) SHPM patient care and

P.M.

P.M. Students hour with consultant SHPM patient care and

P.M. Family counseling /psychodynamics SHPM patient care and

tasks (Ward rounds/OPD)

tasks (/Ward rounds/OPD)

tasks (/Ward rounds/OPD)

2nd week Monday A.M. Palliative Care team meeting SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation P.M. Students hour: End of Life (Dr. Bausa) SHPM patient care and tasks (Ward rounds/OPD) 3rd week Monday A.M. Orientation with fellow of the month and consultant

Tuesday A.M. Students hour: Pain and common symptoms in hospice lecture (Dr. Ang) Case Management Meeting (9am to 10:30)

Wednesday A.M. Palliative Care team meeting SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. Students Didactic session with Senior Resident SHPM patient care and tasks (Ward rounds/OPD CI 108)

Thursday A.M. DFCM Staff conference

Friday A.M. Palliative Care team meeting SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. Junior Journal Club (student evidence based presentation) SHPM patient care and tasks (Ward rounds/OPD)

SHPM patient care and tasks (Ward rounds/OPD)

P.M. Students hour with consultant SHPM patient care and tasks (Ward rounds/OPD)

P.M. Family counseling /psychodynamics SHPM patient care and tasks (Ward rounds/OPD)

Tuesday A.M. Students hour with consultant

Wednesday A.M. Palliative Care team meeting

Thursday A.M. DFCM Staff conference

Friday A.M. Palliative Care team meeting

Palliative Care team meeting SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. SHPM patient care and tasks (Ward rounds/OPD) Case Management Meeting (9am 10:30)

SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation)

SHPM patient care and tasks (Ward rounds/OPD)

SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation)

P.M. Students hour with consultant SHPM patient care and tasks (Ward rounds/OPD)

P.M. Students Didactic session with Junior Resident SHPM patient care and tasks (Ward rounds/OPD at CI 108)

P.M. Family counseling /psychodynamics SHPM patient care and tasks (Ward rounds/OPD)

P.M. Junior Journal Club (student evidence based presentation) SHPM patient care and tasks (Ward rounds/OPD)

4th week Monday A.M. Palliative Care team meeting SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. Students hour with

Tuesday A.M. Students hour Case Conference/Grand rounds

Wednesday A.M. Palliative Care team meeting SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. Students Didactic session

Thursday A.M. DFCM Staff conference

Friday A.M. Palliative Care team meeting SHPM patient care and tasks (Home visit/Ward rounds/OPD Child-Family Supportive Care Program rotation) P.M. Junior Journal Club

SHPM patient care and tasks (Ward rounds/OPD)

P.M. Students hour with

P.M. Family counseling

consultant (Dr. Bausa) SHPM patient care and tasks (Ward rounds/OPD)

consultant SHPM patient care and tasks (Ward rounds/OPD)

with Senior Resident SHPM patient care and tasks (Ward rounds/OPD at CI 108)

/psychodynamics SHPM patient care and tasks (Ward rounds/OPD)

(student evidence based presentation) SHPM patient care and tasks (Ward rounds/OPD)

Course faculty: Andrew Ang, MD Agnes Bausa-Claudio, MD Manuel Medina, MD Rachel Rosario, MD

Community Medicine Rotation

Course Description: Community Medicine component of FCH 251; a one-week rotation seeking to provide students with the opportunity to conduct and learn Community Medicine work with vulnerable sectors and integrate into the health referral system.

Learning Objectives: At the end of the 1-week rotation, each Year Level-6 student must be able to:

I. Demonstrate clinical capacities as a primary care physicians. 1. Perform history taking and physical examination with patients seeking consult at the local health center, NGO clinic, community / barangay health posts. 2. Formulate a diagnosis and a diagnostic & treatment plan with the patients seeking consult at the communities, local outpatient clinic and a secondary hospital. 3. Demonstrate skills in patient education: Demonstrate skills & attitude in discussing with a patient and her / his caregiver t he patients illness and the basis for the diagnostic & therapeutic options. 4. Appropriately refer patients for further treatment to better equipped facilities with better skilled health professionals. 5. Appropriately refer patients and their families to community resources and partners in health care.

II. Demonstrate skills & attitude as a health program manager. A. Analyze local, national, and global determinants / factors that affect the health of a population group and individual patients. 1. 2. 3. 4. 5. 6. Identify gaps in health care Define vulnerable, marginalized population groups Describe why these groups are vulnerable or/and marginalized. Describe the health status of a specific marginalized population. Analyze the social determinants affecting health of populations. Define globalization and its positive and negative effects on health

B. Describe local, national, global efforts to address health and social issues of a specific marginalized population. 1. Describe elements of health programs and systems management 2. Participate in program implementation and management to address health and health-related needs. 3. Analyze how the intervention/s address/es needs of the identified population group/s

Concept Map:
GLOBAL / NATIONAL SITUATION Global / National Health Situation

SOAP: Problem Solving Paradigm

UPCM V-M-G
*Primary Health Care Philosophy *Rights-Based Approach to Development Liberating Approach to Education

Economic Political Socio-cultural Environmental Geographic

DETERMINANTS

Local National Global RESOURCES

Hospital-Based Programs

HEALTH REFERRAL SYSTEM 1* 2* 3* Health

Community-Based Programs

Facilities
GAPS IN HEALTH CARE
The Health of Vulnerable Population Groups: Street Children Persons w/ HIV-AIDS

LOCAL HEALTH SYSTEMS DEVELOPMENT, Partnership and Referral

List of must-know and nice to know topics Session Faculty Topic 1 Portia Marcelo Bridge review of Community Medicine topics in previous years 1. The Philippine Health Care System 2. The Public Sector 3. The Voluntary Sector Achieving equity in health, the PHCA Health of Vulnerable Population Groups Social Determinants of Health, Globalization Experiences from the Field: Community Medicine as a Career Option ELEMENTS: Essential/ Basic Health Services / Programs: IMCI {EPI, CARI, CDD, Nutrition}, NTP, Maternal Health {Antenatal and Post-Partum Care} Preceptorials in the Local Health Center, NGO clinic & field sites 1. Clinical case management 2. Clinic management 3. Special Features for emphasis: 1. The Local Health Center 2. Health NGO and Field Sites Comparative Health Care Delivery Systems and Elements of Health Program / Services Management ComMed Rotation Evaluation

2 3 4

Edelina DelaPaz, RPP Alumna/-us * * Portia Marcelo Edelina Del Paz Christian Gomez others

5*

Clinical Clerks Guide to Duties at the Pasay Health Centers I Introduction This segment of FCH 251 has the same learning objectives [and evaluation parameters] in a different venue, i.e. a stand-alone public primary care health center. This aims to expose the students to resources and issues related to managing a local primary health facility and its component public health programs. II Expected behavior among Clinical Clerks - the bases of your performance evaluation in this rotation.

Courtesy to Health Center Staff and Patients. Introduction to the Health Center Staff: Introduce yourselves to the Doctor-and- Clinic-and Health Programs Manager, and his/her staff [sign in their logbook]. Get to know the Center Staff, including the BHWs. Observe their assigned duties. Learn about the processes, materials and activities in running a health center. Report to Dr. Armand Lee and Ms. Luz Dino {Malibay HC} as well as our DFCM resident physician Dr. __, everyday at 8:00 am. Take the initiative to set up your consultation room put the room, tables and chairs in order; while totally impossible, try to arrange the furniture for comfort and privacy. Set up your computer and log into CHITS. Reminder: Be courteous, every time, every day! Take the initiative to greet all the Health Center staff; you are entering their home, their turf. They do not know you; though they could be busy with the businesses for the day, they expect a greeting with a smile from each of you all the time. Be respectful to the patients. Observe and immerse into their lifestyle; as newcomers, you are EXPECTED to respect their processes. {There will be another venue for constructive critique.}

Be intellectually prepared. Review Care of well child, pregnant women; health promotion across ages. Diagnosis and management of common illnesses among ambulatory patients: IMCI [includes ARI, AGE, EPI, malnutrition, etc based on WHO-UNICEF protocols]; dermatoses, dyspepsia, hypertension and TB (review the WHO-DOH-NTP/National TB Program protocol). how to compute for appropriate dosages of common antibiotics and drugs for children

Your notes on the patient flow in the Health Center, to avoid delays. Your notes on logging into and recording patient transactions in CHITS. Every morning, check what are the available medicines and preparations in the Health Center pharmacy. Use the list to guide your choice of drugs and how to compute for correct doses. Remember, prescribing appropriate and available drugs improve patient adherence to therapy. Be prepared to discuss any of your patients with your resident and/or consultant. Make sure all your patients will be seen by any of them.

What to bring, what to wear. ALL THE TIME Bring YOUR OWN basic MD stuff: stethoscope, sphygmomanometer [great if you have a pedia cuff], pen light [with working batteries], measuring tape, clipboard and pens, neurologic hammer, gloves, calculators and PNDF/ National Drug Formulary {or MIMS or PDR commercially available). ALL THE TIME per pair, Bring YOUR OWN laptop and diagnostic set {ophthalmoscope and otoscope). Good to have your own set of tongue depressors, they run out fast. Bring your own personal stuff- water to drink, umbrella to protect you from the rain and sun, candies to stave off hypoglycemia and keep you smiling. What to wear: Clean white uniforms and nameplate, closed shoes. Leave unnecessary jewelry and valuables at home. Be responsible, keep your money / wallet and mobile phones in your pocket at all times. III Learning Activities 1. Opportunities for Patient Education: 1. Observe the Pre-con, pre-consultation lecture [a.k.a. Public Health Lecture in UPCM-PGH parlance], and Post-con, postconsultation discussion to be given by the Center staff. Note also the posters, flyers given to patients and other strategies for patient education. COMPARE this with how you did these kinds of health education in the past in LU3, 4, 5 [including your monthly COME activities teaching the BHWs]. 2. When assigned in the Wellness Clinic - where infant immunization and prenatal care happens, observe the Post-Con - how nurses and midwives iterate the physician's advise (both about medication intake, supportive care, date of follow-up). 2. CHITS Community Health Information and Tracking System Data for decision making / Evidence-based decision-making: use

electronic medical records for health information management, i.e. data collection, collation, retrieval, analysis and information for decision-making 3. Observe / learn about how basic health services subsidized by the government are implemented in a typical health center. Note the following: 1. Division of labor among the different types of health professionals 2. Health records/ data management via CHITS 3. EPI {Expanded Program for Immunization, including cold chain management} 4. Essential drugs provision 5. Maternal health {Pre- and post-natal care, including vaccinations, breastfeeding advice, nutrition monitoring and family planning counseling} 6. Malnutrition among children 7. Management of common illnesses / injuries 8. TB case management based on the NTP visit the UPMASA-supported TB-DOTS Clinic 9. others 4. Patient care: Each day, assign 1-2 students III. To see sick patients, IV. To assist wellness consults with nurses and midwives {EPI on MW, Prenatal Care on TTh}. Each patient needs to be presented to the resident and/or consultant BEFORE you discharge them. Make sure you get to experience both sections of the health center. V. As in the ER-Ambulatory Section, see all patients seeking consult at the Local Health Center. Keep a log of your patients using the format initially prescribed during your Course Orientation, similar to the one below:
Patients Name Age Sex Bgy Chief Complaint Diagnosis Disposition

VI. This will be used in the analysis of case mix, and over all evaluation of clinic management at the end of your Community Medicine rotation in FCH260. Be prepared to discuss with the consultant on duty any of the cases of patients you attended to. [You need not ask the patients to stay behind unless you think they need further evaluation.] III HOMEWORK: TO BE SUBMITTED ON MONDAY OF after your FCH 251 rotation. Complete the Comparative Health Care Systems matrix D, using the basic guide questions listed:

What are the common clinical cases seen in the health center? How do they compare with patients in the PGH? In private practice? What are the activities in the health center? PGH? In the clinic of private practitioners? In the NGOs? What resources does the Health Center have? PGH? Clinic of private practitioners? The NGOs? What is the experience of a patient seeking consult at the health center? PGH? Clinic of private practitioners? In the NGOs? Characterize the relationships among the clinic staff in the local health center? PGH? Clinic of private practitioners? In the NGOs?

Clinical Clerks' Guide to Fieldwork with Health NGOs Street children and the ChildHope Asia Philippines,

Introduction: Rationale

This session with Childhope Asia Philippines is an opportunity for a personal encounter with street children in their setting. This provides practical experience of the discussions on health of vulnerable groups, enfleshing issues, putting faces to the problem; it is a first-hand experience in evaluating the health of street children. Childhope Asia is an international non-profit, non-sectarian, non-political organization whose primary purpose is to advance the cause of street children throughout the world. Rotary Club of Honolulu, a partner, donated a mobile clinic with state-of-the-art medical equipment; medical supplies are continuously provided by other partners from the private and voluntary sectors. Childhope Asia Philippines also works with the national (Department of Social Welfare and Development) and local (city) governments in order to converge efforts towards ultimately getting the children off the streets. This learning activity with Childhope Asia Philippines has the same learning objectives and methodology as that of your tour of duty at the ambulatory clinics in PGH of the Department of Family and Community Medicine, i.e. 2B05 at the OPD and the Ambulatory Care Section of the ER. However, this is held in a different venue a mobile clinic amidst where street children amass and run primarily by a private volunteer organization. It aims to hone your clinical skills, and expose you to social determinants that greatly affect the health of the kids. For the target children, this would be their (perhaps only) chance to receive proper and thorough care. It provides opportunity for you to critique systems in order to improve them. The formal health care system, in both government and private sectors, has rendered itself socially, financially and culturally inaccessible because of the issues that beleaguer street children. In the context of service-learning, this is UP's part in contributing its capacities to improve health systems, uphold children's rights and make it more responsive to the needs of vulnerable sectors. II Methodology

Report to the site where the Childhope mobile clinic will set up, noting physical arrangements and available medical supplies that you may need in patient care. A thorough clinical history and physical examination is expected of you, please note them carefully in your notes. Dr. Harvey Carpio / Dr. Cheryl Magbanua, UPCM'06, and the assigned DFCM resident and/or consultant will supervise your work, and discharge the patients from your care with finality. You're expected to be on site from 230-5pm.

What to bring: (1) basic MD stuff- stet, sphygmomanometer [great if you have a pedia cuff], flashlight, diagnostic set per group, measuring tape, neurologic hammer, gloves; (2)clipboard and pen; (3) personal stuff- water to drink, umbrella to protect you from the rain and sun, candies to stave off hypoglycemia and keep you smiling. What to wear: Be in uniform, with nameplate, closed shoes [when in the Childhope or RAF clinic].

Community Medicine Discussion Series #2 Health of Vulnerable Population Groups1 I Objectives: At the end of the session, students should be able to 1. Define vulnerable, marginalized population groups from a health and 'power' perspective. (a) Describe why these groups are vulnerable or/and marginalized. (b)Describe local, national, and global determinants / factors 2. Describe the health status of a specific marginalized population. 3. Describe local, national, global efforts to address health and social issues of a specific marginalized population. (a) Analyze how the intervention/s address/es needs of the identified population group. 4. Reflect and describe concept/s previously discussed that is of personal and professional relevance to the students. Guide questions: Describe the vulnerable, marginalized population group. Why are they vulnerable, marginalized? What is the health status of this specific population? Why what factors affect their health? Describe local, national, global efforts to address health and social issues of a specific marginalized population. Do these efforts rationally address the needs of the population concerned? Do the interventions uphold principles of Primary Health Care?

II a) b) c) d)

Marcelo,PF and EP delaPaz. July 2005. Health of Vulnerable Population Groups. Revised June 2007

Community Medicine Discussion Series #3 Social Determinants of Health, Globalization and Health2 References: 1. WHO Commission of the Social Determinants of Health. March 2005. Action on the Social Determinants of Health: Learning from Experiences 2. Whitehead, M and G Dahlgren. 2006. Leveling up [part1]: Discussion Paper on Concepts and Principles for Tackling Social Inequities in Health 3. Renewing Primary Health Care in the Americas: Position Paper of the PAHO/WHO. March 2007 4. United Nations Millennium Development Goals: Health Related Goals.2000 5. Werner and Sanders, 2000 Chapters 3 and 4. Questioning the Solution: The Politics of PHC 6. Walsh and Warren, 1979. Selective PHC as an Interim Strategy

2 EPDelaPaz, version3_June2007, Poverty, Social Determinants, Globalization and Health

Community Medicine Discussion Series #4: Experiences from the Field: Community Medicine as a Career Option 3 Objectives: At the end of the session, students should be able to Describe the work of the Community Medicine practitioner 1. Describe features of the area where our guest-alumnus/a practices 2. List health and health related issues in the area of work of the Community Medicine practitioner 3. Define how these issues were addressed. 1. Analyze the intervention/s using the PHC framework Describe factors that influenced the career choice/s of our guest-alumnus/a Reflect and describe concept/s previously discussed that is of personal and professional relevance to the students. Community Medicine Discussion Series #5: ELEMENTS: Essential Health Services and Programs: [IMCI, TB, Maternal Health]4 Objectives: At the end of the discussion, students should be able to 1. Analyze and diagnose clinical conditions [i.e. TB, childhood illnesses, care of pregnant women] using the ecological model. 1.1. Analyze and diagnose clinical conditions using the force field theory of analysis. 2. Define solutions to clinical issues using an ecological approach to health. 2.1. Describe national government programs [i.e. TB, childhood illnesses, care of pregnant women] as these are implemented in an urban local health center. 2.2. Describe private sector involvement in these concerns.

3 4

Marcelo, PF. July 2005. Experiences from the Field: Community Medicine as a Career Option

PFMarcelo. June 2004- structured learning materials prepared for TB-- see SIM on TB Modules 1-5; IMCI and Maternal Health discussed during orientation to Pasay HC duties; updated June 2005. ELEMENTS: Essential Health Services and Programs

Community Medicine Discussion Series #6 Comparative Health Care Delivery Systems and Elements of Health Program / Services Management5 I Introduction This discussion is scheduled towards the end of the students' tours of duty at the PGH Family Medicine Clinic - Ambulatory Care Section/ER and the Pasay local health center, a private practice clinic, clinics and field sites of health NGOs, and the Pasay City General hospital. II 1. 2. Objectives: At the end of the discussion, students should be able to Describe the public and private health care delivery systems Describe the function and rationale of elements of health care delivery: policies / programs systems, people [patient base, health providers, managers and policymakers], IEC/ Information-education-communications [opportunities for patient education, medical records management through CHITS], equipment, supplies and facilities [waiting room, clinics, diagnostic, therapeutic supplies], financing of services. Describe and contrast elements of health care delivery 3.1. in different primary care settings: PGH Family Medicine Clinic - Ambulatory Care Section/ER, the Pasay local health center, a private family practice clinic, field sites of health NGOs 3.2. in a primary care setting and a public tertiary, teaching hospital Reflect and describe concept/s previously discussed that is of personal and professional relevance to the students.

3.

4.

Course Faculty: Portia Marcelo, MD, MPH (Course Segment Coordinator) Edelina dela Paz, MD Christian Gomez, MD Ramon P. Paterno, MD MPH

Ambulatory Care Unit rotation

Course description: This is a 1-week clinical rotation in the Ambulatory Care Unit within the area of the PGH Department of Emergency Medical Services. The rotation in the Ambulatory care unit (AMBU) setting covers primarily non-trauma adult and pediatric ambulatory cases usually triaged as non-emergency/urgent cases. Students will be trained in the context of first-contact care physicians dealing with the more common clinical conditions found in the general population, delivering basic services and performing simple interventions usually performed by generalist physicians in an ambulatory setting. Patients in this area may present with acute medical problems that may be of new onset, exacerbations of chronic conditions, with either protean manifestations or frank symptoms pointing to specific organs that may eventually need specialist referral. In between duty days, students will have opportunities to join staff conferences and case presentations, do independent readings, reflect on the possible areas of future professional practice and deal with personal issues in the context of work-life balance.

Pre-requisites:

Students must have successfully passed all the requirements of LU5. They are also expected to know and apply the principles of Family Medicine, the biopsychosocial approach, pharmacology of medications used in the ambulatory care section, common morbidities seen in the emergency room (with special note of the Ambu statistics). The DEMS-Ambu section takes care of adult and pediatric patients initially triaged by the DEMS to be non-emergency. As such, the cases seen may be considered as urgent or non-emergent. While the section deals primarily with non-trauma patients, patients needing outpatient procedures (such as tetanus prophylaxis) may also be sent to this area. 5 duties (total of 40 hours)

Description of training area:

Required number of duties/student:

General objective:

To provide the LU6 student with the appropriate clinical exposure as first-contact care physician managing the most commonly encountered acute cases encountered in family practice / generalist setting.

Learning Objectives Given actual patients in the DEMS Ambulatory Care Unit, an LU6 student should :

Content

Activities

Resources

Assessment

1. Conduct primary survey of patients with potentially life-threatening condition

General assessment: vital signs Principles of triaging

Patient identification Taking vital signs Brief history

Ambulatory care unit Actual patients (adult and pediatric)

Performance evaluation (to be filled by supervising resident/consultant)

2. Elicit a complete history

History-taking: Pediatric and adult history (biopsychosocial history/psychiatric history) as indicated

History-taking Recording PE findings

PGH patient records

Report of Activities

Reflection paper / Feedback form

3. Perform a complete physical examination, with special attention directed on abnormal Physical examination findings (adult & pediatric) Patient-doctor relationship Confidentiality; bioethics 4. Formulate a working diagnosis

Conducting physical Examination (adult/pedia) Recording PE findings

Stethoscope, weighing scale, BP apparatus, thermometer, diagnostic set, neurologic hammer, tongue depressor

Differential diagnosis Common morbidities Common diagnostic procedures Pharmacology Clinical Practice guidelines for the most common conditions Supportive management Principles of prevention

Critical thinking

References: Harrison's Principles of Internal Medicine, Textbook of Pediatrics, Medicine Bluebook, Compendium of Philippine Medicine PGH morbidity statistics

5. Formulate a management plan for the patient

Critical thinking

6. Perform simple procedures usually done in a generalist setting

Common procedures: Blood extraction, nebulization, intramuscular/intravenous injections; NGT. Foley catheterization Principles of universal preCautions

Obtaining, handling and transporting specimens, while observing universal Precautions

Syringes, gloves, alcohol, cotton balls, tourniquet, KY gel, neb set, plaster, gauze

7. Correctly interpret basic laboratory tests

CBC, basic radiology, blood chemistries, interpreting and EKG correlating lab tests

8. Refer appropriately

Management guidelines

Writing referrals

PGH referral forms

9. Provide patient and family education about the illness

Basic pathophysiology Basic pedagogy Preventive strategies Basic counseling skills: CEA, motivational counseling Biopsychosocial approach Family assessment tools

Bedside education

Educational materials Printed visuals/prompts

10. Address relevant biopsychosocial issues that may affect Adherence

Bedside education Counseling

Family medicine lecture notes

11. Identify community resources and linkages that patients and families may utilize for the management of the illness

PGH-community referral system DOH programs Philhealth / health insurance PCSO, NGO

Providing referrals that include history, reason for referral

Listing of health centers, hotlines Hospital directory

12. Demonstrate the attributes of an ADULT LEARNER

13. Demonstrate the desired characteristics of a health professional and Decent human being

Principles of adult learning Evidence-based medicine Communication and critical thinking skills Communication skills Values and professional ethics Health economics Work-life balance Self-care Spirituality, EQ. AQ Giving and receiving feedback Organization and management

Perform critical appraisal of relevant literature Participation in group Discussions Patient-doctor consultation

Computer with internet access Appraisal guides

Reflection paper Learner portfolio (report of activities, etc)

Books, hand-outs Consultant and resident

Performance evaluation Patient feedback Report of activities

Readings and reflection Small group discussions Interpersonal communication

as role models

List of must-know and nice to know topics: The Case for a New Philippine Health Referral System. UP Manila Bagumbayan. Real-life drama in the emergency room. The Philippine Star. July 11, 2000. An Evidence-Based Update on NSAIDs. CM & R. March 2007 Emergency medical care in developing countries: is it worthwhile? Bulletin of the WHO, 2002. The Occupational Hazards of Emergency Physicians. Bulletin of the WHO.2002. Underestimation of Case Severity by Emergency Department Patients Implications for Managed Care. American journal of Emergency Medicine. May 2000. The Short-stay Emergency Observation Ward is Here to Stay. American Journal of Emergency Medicine. September 2000.

Class schedule/blueprint of activities: A. Ambu duties Schedule 6:00 AM-2:00 PM 2:00 PM-10:00 PM 10:00 PM-6:00 PM 6:00 AM-2:00 PM 2:00 PM-10:00 PM 10:00 PM-6:00 PM *Duty hrs/student: Day 1 Orientation 1 2 Day 8 5 6 7 Day 2 3 4 1 Day 9 8 5 6 Day 3 2 3 4 Day 10 7 8 5 Day 4 1 2 3 Day 11 6 7 8 Day 5 4 1 2 Day 12 5 6 7 Day 6 3 4 1 Day 13 8 5 6 Day 7 2 3 4 Day 14 7 8 Off

40 hours

B. Weekday Department Conferences: 7:00 AM -8:00 AM 8:00 AM -9:00 AM 1:00 PM -2:00 PM Endorsement conferences (with residents and Interns) *EBM conference - every Thursday Conferences for special topics (TBA) *Department Staff Conference Thursday (starting 8:00 AM) Conferences for special topics (TBA)

C. Special conferences UPCM (TBA) Tuesday 8:00-10:00 Pharmacology modules (TBA)

List of Faculty member/s for Ambulatory care rotation: MARIA CONSUELO BALITA-PUMANES, MD, MHPEd ( Course Segment Coordinator)

Prepared by: Andrew E. Ang, MD, FPAFP LU6 Department of Family and Community Medicine Coordinator