Primary Care Clerkship

The Biopsychosocial Approach to the Patient (BAH) is a 12-week integrated clerkship block comprised of Psychology 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 and treatment of somatic symptoms, 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 Federally Qualified Health Center, and Yale Internal Medicine Associates. Course 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 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 portion 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 clerkship 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 clerkship 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 clerkship 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 clerkship (in the “yellow book” sent to each student and preceptor).

• Demonstrate behaviors consistent with the highest standards of professionalism and medical ethics in all patient encounters.
• Incorporate core concepts for primary care and psychiatry during the care of patients.
• Obtain an accurate and appropriately focused medical history for a specific setting and amount of time.
• Complete an appropriately focused, accurate physical and mental status examination for an adult or child patient.
• Formulate and describe the differential diagnosis and a diagnostic plan for children and adults presenting with various complaints in primary care or psychiatry.
• Deliver an effective oral presentation and write notes based on the findings from an interview and examination of an adult or child in primary care or psychiatry.
• Ascertain and interpret the results of common tests.
• Develop, describe, and implement appropriate therapeutic plans.
• Demonstrate the learning skills and ability to identify and meet emerging information needs for diagnosis, prognosis and treatment of patients cared for in primary care or psychiatry.
• Demonstrate skills for coordination of care and communication with colleagues.
• Demonstrate the knowledge required to provide care for patients presenting with the most important and common needs in psychiatry and the three domains of primary care (i.e., evaluation of symptoms, preventative health, and chronic disease management).
• Recognize and diagnose selected emergencies in primary care and psychiatry and describe the initial approach to management of each.
• Demonstrate the ability to deliver evidence-based brief behavioral interventions.
• Recognize the various ways in which primary care and psychiatry in the United States are practiced and the mechanisms/forces which have shaped primary care and psychiatry.
• Describe benefits of providing mental health within primary care practice.