Primary Care Component

Biopsychosocial Approach to the Patient (BAH) is a 12-week integrated clerkship block comprised of Psychiatry and Primary Care. Integration of training in Primary Care and Psychiatry occurs in two areas. First, in didactics, all students assemble together to complete “Top Ten” workshops on topics spanning both disciplines, e.g., assessment of competency, treatment of chronic pain, motivational interviewing, diagnosis, treatment of somatic symptoms, and addressing social determinants of health. Additionally, students participate in three individual workshops a) introduction and rationale for the biopsychosocial approach with readings (e.g., George Engel, Barbara Starfield), b) clinical approach to the biopsychosocial model and c) how patients access community health and psychiatric resources. In the clinical realm, many sites have embedded psychiatric services, e.g., West Haven VA Medical Center, the New Haven Health Consortium, Cornell Scott Hill Health Center, and Yale Internal Medicine Associates. Clerkship Directors (CDs) communicate with preceptors at all sites before students arrive, emphasizing the clerkship’s goal to teach a holistic approach to patient care. Additionally, to promote exchange of ideas across Primary Care and Psychiatry faculty, CDs prepare and host regular evening faculty development events focusing on topics of interest to both Primary Care and Psychiatry faculty.

The Primary Care component of the clerkship takes place over 6 weeks, wherein students work in outpatient settings under the supervision of primary care clinicians for 9 clinical sessions per week split between pediatric and adult settings and attend didactics for one afternoon. The direct clinical training enables students to gain knowledge in all aspects of patient care including the interview, physical exam, interpretation of lab and radiologic results, motivational interviewing, patient education, and telehealth delivery. Preceptors provide daily individualized coaching and feedback to assure that students meet individual learning goals. Additionally, preceptors role model the therapeutic, longitudinal doctor-patient relationship and caring for patients in the context of family, community, culture, and social determinants of health.

Students’ primary learning occurs in a) the clinical arena where they assume an appropriate degree of autonomy in direct patient care supplemented and enriched by b) daily reading and c) didactic experiences. Students participate in a Problem-Focused Patient Examination Workshop to learn how to efficiently set an agenda, elicit concerns, interview, generate a differential diagnosis, and formulate a treatment plan. Weekly didactics occur on Thursday afternoons, including workshops and Peer Teaching conferences. Workshops include common conditions encountered in Pediatrics and Internal Medicine, e.g., asthma, diabetes mellitus, hypertension, obesity, orthopedics, and principles of screening. Each student leads a 30-minute Peer Teaching workshop on topics commonly evaluated in primary care such as headache, anemia, concussion, or constipation and receive feedback from faculty to improve the content and quality of their teaching.

While the grading of student performance in the primary care component of the clerkship is pass/fail, students receive a set of holistic assessments and feedback on their nascent clinical skills including -

1. Goal setting: Preceptors meet with students at beginning of component to discuss mutual goals. Students ask preceptors for formative feedback on a daily basis using a “coaching” model.
2. Formative evaluations: At the beginning, mid-point, and end of component each preceptor completes a written assessment of student performance regarding interview skills, physical examination, and written notes. These detailed written comments about strengths and areas for improvement aim to improve student performance in the domains of professionalism, knowledge, and clinical skills.
   • Each student completes sixteen Aquifer (computer simulation assessing clinical reasoning and knowledge) cases and receive immediate feedback.
   • Additionally, students complete a 75-item knowledge-based self-assessment and receive immediate feedback (which does not factor into the clerkship grading).
3. Summative evaluations: Each preceptor completes MedHub evaluation forms for each student at the end of the clerkship. CDs provide preceptors with examples of helpful (detailed, specific) vs not helpful (vague, general) feedback to improve the quality of feedback.

The integrated component specifies 15 learning objectives spanning knowledge, skills, and attitudes - e.g., professionalism, interviewing skills, clinical reasoning - and distributes these to the students and preceptors at the beginning of the primary care component (in the “yellow book” sent to each student and preceptor).

• Appreciate the epidemiologic principles supporting screening of patients and communities.
• Demonstrate the ability to provide health maintenance and preventative care including screening, counseling, and immunizations for patients.
• Describe benefits of providing mental health care within primary care practice.
• Demonstrate the ability to deliver brief evidence-based behavioral interventions.
• Learn the clinical knowledge and apply basic science concepts to evaluate and treat common presentations in primary care.
• Use clinical reasoning to synthesize data into a prioritized differential diagnosis and plan.
• Demonstrate behaviors consistent with the highest standards of professionalism and medical ethics in all patient encounters and interactions with colleagues.
• Demonstrate effective communication with patients, families, and all members of the healthcare team.
• Obtain an accurate and appropriately detailed medical history in a logical and organized manner for a given clinical setting.
• Complete an appropriate and accurate hypothesis-driven physical examination.
• Deliver an effective oral and written presentation, appropriately tailored for a given clinical setting.
• Recognize whether to obtain and how to interpret common diagnostic studies in primary care.
• Demonstrate skills for coordination of care.
• Demonstrate the skills required to provide care for patients presenting with acute symptoms, for preventative health, and for chronic disease management.
• Recognize and diagnose selected emergencies in primary care and describe the initial approach to management.
• Demonstrate sensitivity and responsiveness to diverse patient populations.
• Appreciate how patient health care needs are impacted by social and structural drivers of health and recognize the role of social determinants of health (SDH) screening and intervention in primary care.
• Understand and practice the attributes of high-quality primary care for children and adults.
• Recognize the various ways in which primary care in the United States is practiced and the mechanisms/forces which have shaped primary care.
• Utilize effective methods of acquiring and applying evidence-based practices to guide diagnosis and treatment decisions.
• Appreciate the overlapping skills, knowledge, and approach to patient care in primary care and psychiatry through shared learning activities.