Medicine Core Clerkship Handbook

JOHNS SHOPKINS UNIVERSITY SCHOOL OF MEDICINE
MEDICINE CORE CLERKSHIP HANDBOOK
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
MEDICINE CORE CLERKSHIP

HANDBOOK
Danelle Cayea, MD, MS

Director
Bruce A. Leff, MD
Co-Director
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CLERKSHIP CONTACTS:
Danelle Cayea, MD, MS

Director
Medicine Core Clerkship
Associate Professor of Medicine
The Johns Hopkins University School of Medicine
5200 Eastern Avenue
Suite 2200
Baltimore, MD 21224
Office: (410) 550-3553
600 N. Wolfe Street, Nelson/Harvey Bldg

8th floor administrative office – RM 824
Baltimore, MD 21205
dcayea1@jhmi.edu
Bruce A. Leff, MD
Co-Director
Professor of Medicine
Johns Hopkins Geriatrics Center
5505 Hopkins Bayview Circle
Baltimore, Maryland 21224
Office: (410) 550-2654
bleff@jhmi.edu
Jennifer Weaver
Medical Training Program Coordinator
600 N. Wolfe Street, Nelson/Harvey Bldg
8th floor administrative office – RM 803
Baltimore, MD 21205
410-955-9655 (office)
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Table of Contents
Goals And Objectives Of The Clerkship ........................................................................... 4

How To Succeed On The Clerkship .................................................................................. 8
Your Schedule .................................................................................................................... 9
Johns Hopkins Bayview Medical Center: ............................................................................................................................9
Johns Hopkins Hospital: .................................................................................................................................................... 11
Sinai Hospital: ................................................................................................................................................................... 12
Mini – Clinical Exercise (Mini-Cex) ............................................................................... 13
Duty Hours ....................................................................................................................... 15
Expectations For Nights On-Call “Long Call” And For “Short Call” - Faq ................... 16
Johns Hopkins Hospital Clerkship Night Shift Guidelines……………………..……...18
The Medicine Service ...................................................................................................... 18
Write-Ups ......................................................................................................................... 19
Writing Orders ................................................................................................................. 19
Oral Presentations ............................................................................................................ 21
Performance Goals And Grading Policy.......................................................................... 23
Feedback – Strategies To Obtain Feedback ..................................................................... 27
From Dean For Education To Clerkship Directors, Memorandum On The Grading
System .............................................................................................................................. 28
Oasis/Patient Tracker – Logging Your Patient Encounters During The Clerkship ......... 30
Ultravisual System ...........................................................Error! Bookmark not defined.
New Innovations: Online Evaluations For The Medicine Clerkship............................... 33
Student Attendance Policy ............................................................................................... 36
Professionalism Concerns ................................................................................................ 40
Invasive Procedures ......................................................................................................... 40
Student Injury (Occupational Health) .............................................................................. 40
On-Line Resources ........................................................................................................... 39
Student Assistance Program............................................................................................. 43
Student Mistreatment Policy: Guidelines For Conduct In Teacher/Learner
Relationships .................................................................................................................. 43
Weather Issues.................................................................................................................. 44
Email Use ......................................................................................................................... 44
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INTRODUCTION
Welcome to the Medicine Core Clerkship! We view this as one of the most important experiences you
will have in medical school. Regardless of the field in medicine you eventually pursue, your
experience on this clerkship will provide you with the opportunity to acquire and enhance basic skills
that will form the foundation for your medical career. YOU WILL NOT, NOR IS IT EXPECTED that
you will, master the depth and breadth of internal medicine during this clerkship. However, the
clerkship experience can help you develop a framework to continue to develop your medical skills for
decades to come. During this clerkship you will have the opportunity to:
1. Provide medical care to patients as a member of a team of health care providers. Working with the
housestaff and attending physicians you will have the opportunity to be the primary physician for
patients;
2. Expand and integrate your fund of knowledge in medicine;
3. Improve your history-taking and physical examination skills;
4. Improve your oral case presentation skills;
5. Improve your ability to integrate complex clinical information in the service of your patients;
6. Observe at close range many attending physicians, resident physicians, and other health care
providers in their work.
GOALS AND OBJECTIVES OF THE CLERKSHIP

The overall goal of the Medicine Core Clerkship is growing independence. An effective, confident
physician successfully combines personal qualities of compassion and commitment with an ever
evolving knowledge base to complement sharpened academic and clinical skills.
The learning goal of the clerkship as it relates to skills, knowledge, and attitudes are as follows:
By the end of the clerkship the student should:
1. Demonstrate professional behaviors including reliability and commitment, response to

instruction, self-directed learning, patient interactions, appropriate response to stress, and
respectful working relationships.
2. To improve fund of knowledge in internal medicine and begin to develop the critical mass of
information needed to care for medical patients for inpatient training problems as defined by
Clerkship Directors in Internal Medicine (CDIM) curriculum guide (see below).
3. Be able to demonstrate communication behaviors to accomplish the three functions of the

medical interview: data gathering, therapeutic relationship building, and patient education and
counseling.
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4. Perform a complete and accurate history and physical examination.
5. Obtain and interpret basic laboratory test results.
6. Learn how to dissect patient problems by asking questions and using the medical literature and
consultants to understand the medical issues affecting the patient, including issues related to
pathophysiology, diagnosis, and management of the patient.
7. Present patient information to attendings, residents, and colleagues in an accurate and concise
manner.
8. Use information obtained in the history, physical examination, and laboratory data to develop a
problem list that identifies and prioritizes patient problems.
KNOWLEDGE
The major knowledge goal is to improve your fund of knowledge in internal medicine to BEGIN
to develop the critical mass of information you will need to care for medical patients.
You will often be exhorted by your attending and housestaff to “read about your patient” and you
will often hear people say that they are “not reading enough.” What should you read? How should
you integrate your reading with your clinical experience? This is often a mystery for students and
housestaff alike.
In the clerkship, there is no explicit assigned reading list. Topics for reading should be determined, in
part, by the problems presented by your patients. As you encounter patients, try to read about their
medical issues in a major medical textbook. We list essential topics in internal medicine that you are
required to read about in the source of your choice. We recommend relying primarily on a basic
textbook of medicine. There is no required textbook for the clerkship. However, a product “Internal
Medicine Essential for Clerkship Students,” from the American College of Physicians and the
Clerkship Directors in Internal Medicine, is an excellent book – highly evidence-based and very terse –
see url: https://www.acponline.org/essentials. Student members of ACP get a discount on the text and
students may join ACP for free. [Full disclosure – Drs. Cayea and Leff contributed a chapter to this
text. However, they receive no royalties of any sort from the sales of the book.] Other useful
textbooks include general texts such as Harrison’s, Cecil’s, or the Principles of Medicine text.
Although many of you will use “Up to Date,” it is recommended that you do not rely on it as your
primary reading source. Many students find it helpful to purchase a pocket manual for quick
information on differential diagnosis and management (e.g., Pocket Medicine, etc.). In addition, you
should read about common and serious major medical diseases and syndromes and unknowns, e.g.
chest pain, shortness of breath, syncope, fever, weight loss, heart failure, renal failure, liver failure, etc.
Patients presented by other students or housestaff on rounds should prompt reading in basic areas to
augment your fund of knowledge.
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When you go to the text, what should you focus on? What do you need to know about a disease or
syndrome? We hope the following format will help you maximize the value of your reading.
1. Definition of the syndrome or disease

a. Can you explain to another what the disease or syndrome label means? What it
includes/excludes?
b. Diagnosis: Complete diagnosis, classification (is there further diagnosis or classification or
staging?). How is the diagnosis made?
c. Pathophysiology
2. Clinical picture
a. Symptoms, signs, labs
b. Who is at risk for the disease?
c. How do age, gender, race, ethnicity affect the prevalence and presentation?
d. Differential diagnosis – what else can this look like?
e. Natural history – what happens if you do nothing in most patients?
f. Complications
3. Treatment
a. Options for treatment: lifestyle, medical surgical. How effective is treatment compared to
natural history?
b. Safety – how “bad” is therapy? Risks, side effects, costs, contraindications, alternatives
c. What do you need to know about a test?
d. How does it work?
e. How good is it? (sensitivity, specificity, predictive value)
f. How bad is it? (risks of procedure, costs)
g. What are the alternatives?
It is more than likely that your clinical experiences will furnish you with an astounding number of
topics on which to focus your reading. However, you are required to read on the following topics.
These are topics that have been identified in the Medicine Clerkship Curriculum Guide published by
the Clerkship Directors in Internal Medicine (CDIM) and the Society of General Internal Medicine
and several topics added by your clerkship directors. This is a curriculum of training problems that
all clinical clerks should have knowledge of. You should review this curriculum guide online at:
http://www.im.org/cdim/. Click on the link "CDIM/SGIM core medicine clerkship guide."
In addition, CDIM has published a “Primer to the Internal Medicine Clerkship.” This useful
handbook discusses many of the issues addressed in this handbook, but if you are interested in a
complementary source on how to succeed in the clerkship, it is available online at no cost at:
https://www.im.org/resources/publications
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 Cough  Congestive
heart failure  Dyspnea
 Dysuria  Diabetes mellitus  Nosocomial infection
 Back pain  Dyslipidemias  Acute myocardial infarction
 Chest pain  Substance abuse  Gastrointestinal bleeding
 Abdominal pain  Smoking cessation  Venous thromboembolism
 Fluid, electrolyte disorders  Depression  Diarrhea
 Anemia  Common cancers  Thyroid disease
 Hypertension  Altered mental status  Liver disease
 COPD  Acute renal failure
 HIV infection  Pneumonia
Attitudes
The chief attitudinal goals of the clerkship are related to how you interact with patients and to issues
of professionalism.
Medicine requires not only scientific knowledge and the ability to analyze and apply that
knowledge, but also an ability to relate to other human beings. The way in which you relate to and
treat your patients and colleagues is critically important in your ability to be an effective physician
and its importance cannot be overemphasized. You must demonstrate a professional demeanor in
your appearance and your actions. You need to dress in a professional manner. You must maintain
a positive attitude towards and respect for your patients and colleagues and the work of medicine.
The work you do during the clerkship and during the remainder of medical school and in your
training is mentally and physically demanding. However, it is important to remember that it is the
patient who is sick, not you. Maintain compassion for your patients. If you are having difficulties
communicating with a patient, ask for help from those who are more experienced. Avoid making
cynical comments even if you encounter others acting in an unprofessional manner. Do not
disparage other physicians or health care providers or their work.
Showing up for work is a major component of professionalism. We expect you to come to the
clerkship every day except for official days off. However, if you are ill, you should not come to
work. This is especially true during the influenza season. If you are unable to come to the
hospital because of illness, you must notify the clerkship director as well as your team leader.
Honesty is an absolute demand of professionalism. You must always be honest when you report
patient data in your write-ups or on rounds. It is infinitely better to report, “I don’t know” or “I
forgot to do that part of the examination” or “I didn’t order that test” than lying about it. Once
caught reporting that which you did not do, your patients or colleagues will never trust you again.
Professionalism does not mean perfection.
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Skills
The major set of skills to be learned is to obtain, record, analyze, and communicate clinical
information. If the opportunity arises, you should practice procedural skills, but it is not a requirement
of the clerkship.
HOW TO SUCCEED ON THE CLERKSHIP

REMEMBER THESE ESSENTIALS, AND YOU WILL HAVE A PRODUCTIVE AND
ENJOYABLE EXPERIENCE ON THE CLERKSHIP:
General Suggestions:
1. Exhibit respect for your patients and coworkers at all times.
2. Get in the game!! Try, as much as possible, to be the primary care provider for your patient.
Try to be the first on the team to perform the history and physical on the patient. Get the old
records that can be helpful to the case. Discuss your patient with the intern and resident before
rounds. Read about and know everything you can about your patient. If your patient goes for a
procedure, accompany them and see what the procedure entails. Present your patient on rounds
in a succinct manner. At times, you may feel superfluous in the care of the patient, as you will
often be off the wards to attend didactic sessions. Rest assured, you are not! Establishing
quickly a good working relationship with your intern and resident and letting them know you
want to be kept informed of developments on your patients is one strategy to stay involved with
the case. In addition, as a student, you can always contribute by spending time with and getting
to know your patients. Often, this pays off large dividends in the diagnosis and management of
the most complex patients. Finally, be around. Don’t disappear for hours at a time in the
library. Often times, the most interesting opportunities for learning happen when you least
expect them.
3. Work on developing your own skills. Perform medical interviews on your patients each day.
Do a full physical examination on your patients each day. Even if you know the findings on
that patient, doing a full examination will help you develop comfort performing physical
examination maneuvers and sequencing your exam. Review the laboratory data on a daily
basis and be certain you can interpret all the numbers.
4. Work as a team and teach one another. Students are often the most effective teachers for each
other. Watch each other perform interviews and physical exams and give each other feedback.
Practice your presentations on one another. If you have a patient with an interesting finding,
show it to your student colleagues.
5. Demonstrate enthusiasm. The attendings and housestaff are excellent teachers. Enthusiastic
learners motivate teachers. Unenthusiastic learners provide teachers an excuse not to teach.
Ask questions. If you are enthusiastic and involved, your teachers will go out of their way to
teach you and you will be given more responsibility for patient care by the housestaff.
6. It is the policy of this course that scheduled learning activities take precedence over routine
floor procedures (i.e.: ordering tests or drawing blood). If you are challenged about this issue,
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please let the Clerkship Director know. However, if something important is taking place on the
wards (e.g. important family meeting, watching your patient undergo an interesting procedure,
etc.) you are permitted to stay with your patient.
7. PRE-ROUND on your patients, so that you have the most up-to-date information on morning
rounds. Review your impressions about the patient's problems and care plan with the intern
before morning rounds, if possible.
8. You must know your own patients in necessary detail and follow them as if you were totally
responsible for them. Don’t be passive! Step up and accept your role as a member of the team.
9. Read about your patients' problems.
10. IMMEDIATELY inform the Clerkship Directors if you are experiencing any educational
or interpersonal difficulties. We can be of help only if problems are discovered DURING
your rotation.
YOUR SCHEDULE
Each of you will spend half of the clerkship at Johns Hopkins Hospital and the other half at either
Johns Hopkins Bayview Medical Center, Sinai Hospital of Baltimore, or on one of the Brancati teams
at JHH. Each of these sites has things about the patient populations and housestaff team structure that
are unique. All sites provide an outstanding educational experience.
Your schedule for the Johns Hopkins Hospital portion of your rotation will be distributed at
orientation. Details of the schedule at Johns Hopkins Bayview Medical Center and Sinai Hospital of
Baltimore will be distributed on site.
Below is a brief description of the major teaching components/conferences at each of the clerkship
sites:
Johns Hopkins Bayview Medical Center:

 Morning Report -This teaching conference occurs weekdays from 7:45 - 8:30 a.m. The morning
usually starts with a "Question of the Day" presented by one of the ACS. This is usually followed
by a case presentation. After the patient is presented, the differential diagnosis, evaluation, and
management are discussed by one of the faculty. During the last 10 minutes, one of the residents
typically presents a didactic "pearl," often one that is relevant to the preceding case. Each week
there are different "specialty" Morning Reports. Morning report is held in the Medical Education
Conference Center on the main floor of the hospital (next to the library); fruit, coffee and tea are
available.
 Noon Conference - This teaching conference occurs on Monday, Wednesday, and Friday. One of
the faculty discusses an important topic in internal medicine. The discussant is typically an expert
in the area being presented, often one who is not only knowledgeable in the area, but also one who
has contributed to the field. In the first 3 months of the year, an Acute Medicine Course is held in
the Noon Conference time slot. In this lecture series, acute care topics are presented that are of
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particular interest to (new) interns and/or medical students. Noon Conference is held in the
Medical Education Center on the ground floor; lunch is available.
 Medicine Grand Rounds - This teaching conference occurs Tuesdays at noon from early September
until mid-June. The conference generally is divided in two parts. The ACS begins the conference
with an Image of Medicine. Typically a slide is shown of some interesting finding (e.g. pathology,
an x-ray, a rash) and the ACS presents a brief didactic about the patient and the condition. This is
followed by the main presentation, which is typically patient-based. Faculty experts present a
patient (often the patient is brought to Grand Rounds) and the key points of this patient's
presentation and of his/her medical condition are discussed.
 Chiefs’ Rounds with the Chairman and selected faculty - Dr. David Hellmann, the Chairman of
Medicine at Johns Hopkins Bayview, round with teams of residents and students weekly (each
team has this on “good day”). Often students present a patient to Drs. Hellmann or a guest faculty
member, such as Dr. Ziegelstein or Dr. Burton, who then round with the teams at the patient's
bedside. Important aspects of the history and physical diagnosis are emphasized. This is typically
followed by a discussion of the differential diagnosis, evaluation, and treatment.
 Teaching Attending Rounds with the Vice-Chairman - Dr. Roy Ziegelstein, the Vice-Chairman of
Medicine at Johns Hopkins Bayview, meets with Medicine Clerkship students once weekly to
review important topics in cardiovascular medicine. Dr. Ziegelstein discusses the approach to
chest pain, cardiac diagnostic testing (including stress testing), congestive heart failure, and atrial
fibrillation. Occasionally, Dr. Ziegelstein and the students will interview and examine a patient to
emphasize an important part of the history or cardiovascular physical examination. Dr. Ziegelstein
also occasionally reviews specific EKGs to emphasize important aspects of patient evaluation and
management. Rounds with Dr. Ziegelstein usually take place on Wednesdays from 1:00-2:00 p.m.
 Teaching Rounds with Dr. Janet Record - Dr. Record meets with students twice per month for
teaching rounds. These are usually bedside sessions with focus on the physical exam. Rounds with
Dr. Record usually take place on Thursdays from 2:00-3:00 p.m.
 Teaching Session with Dr. Khalil Ghanem – Dr. Ghanem, Deputy Director of Education at
Bayview in the Department of Medicine, meets with the students to teach the fundamentals of
antibiotic management.
 ACS Rounds - Medicine Clerkship students meet once a week with one of the Assistant Chiefs of
Service for a one-hour didactic session in which key topics in internal medicine are discussed (e.g.
anemia, acute renal failure, interpreting pulmonary function tests) and in which the ACS review
best methods to present patients on ward rounds. The sessions are held on Mondays from 1-2.
 Subspecialty Conferences - Subspecialty conferences in Pulmonary Medicine, Cardiology and

Tumor Conference are held each once a week. Students may attend these conferences, but they are
not required.
Team Focus- There are four inpatient teams at Bayview. Each team has a curricular focus for the
residents and include "AIM-HI" (Advances in Medicine-Health Innovations, orange team), behavioral
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health (yellow team), Choose Wisely (judicious use of healthcare resources, red team), and Aliki
(patient-centered care and transitions of care, green team). While residents on every ward team
consider and practice evidence-based medicine, patient-centered care, wise use of resources, and
bedside technology, each team emphasizes a particular piece of the overall package of good patient
care that includes all of these things. By design, the clinical experiences for medical students are
essentially identical across all teams at Bayview. The goals, expectations, call schedule, and formal
clerkship activities will be the same for all students at Bayview, regardless of team. Team-specific
curricular activities (e.g. house calls) are focused on resident-level competencies and students will
neither be required nor expected to participate in extra activities, although these experiences may offer
enhanced learning and time for housestaff and attending teaching. Student participation or non-
participation in resident curricular-specific activities should not influence evaluations of you.
Team-specific resident goals:

AIM-HI: The purpose of this curriculum is to teach housestaff how to expand their use of technology
at the bedside, including iPads, hand-carried ultrasound devices, and imaging software.
Behavioral health: The purpose of this curriculum is to teach housestaff about root causes of behavior
and techniques for coaching behavior change
Choosing Wisely: The goal is to give housestaff the opportunity to be aware of cost of tests/services and
to think critically about the usefulness of tests and other services before requesting. The goal of this
curriculum is not to discourage ordering, but to allow the housestaff to think critically before ordering a
test.
Aliki: The Aliki Team places a particular focus on enhancing the ability of trainees to learn from each
other and their patients, and improve their abilities to provide maximally effective transitions of care. In
order to facilitate resident education in patient-centered care and foster better understanding of patients’
transitions into the community after hospital discharge, there is greater focus on communicating with
outpatient health care providers and on calling patients after discharge to assist in transitions from the
hospital.
Johns Hopkins Hospital:

Your schedule at JHH consists of: AM rounds, noon conference lecture series, Case Management and
EKG conferences, attending rounds, radiology rounds, and noon conference.
 Case Management Conference. The students are presented with a case. Students are provided
minimal information to begin with, and asked to elicit history, order labs, order interventions and
tests, in as much a "real time" way as possible. Drs. Cayea and Leff conduct these sessions.
 EKG Conference. Run for many years by Dr. Brent Petty and highly rated, you learn to interpret
an EKG in an organized and accurate fashion. Dr. Petty conducts his sessions employing a
Socratic method. It is critical to prepare for these sessions.
 Noon Conference. On most Tuesdays and Thursdays at noon there is a lecture series for the
students only.
 Tumulty Rounds: these rounds are named in honor of Philip Tumulty, former head of the Marburg
Medical Service, and renowned clinician, teacher, and educator. He was dedicated to the
importance of patient-based teaching, clinical decision-making, and effective communication.
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Tumulty rounds are led by a member of the general internal medicine faculty who bring a patient to
the conference to present their story as the starting point for a discussion of pathophysiology,
diagnosis, or therapeutics.
 Morning Report. Held 8-9:15 am every Monday through Friday in Harvey 712. Students should
attend when post-night shifts and as time permits on the Brancati service. A patient case from
overnight is discussed with a focus on physical exam and metacognition skills associated with
clinical reasoning.
 Teaching Attending Rounds: Students meet in small firm groups with a firm faculty member 3
times per week. These sessions should focus on skill development at the bedside and may include
history and physical exam practice as well as clinical reasoning discussions.
Sinai Hospital:
The daily routine consists of morning Work Rounds from 7:00-9:00 a.m., Attending Rounds from
9:00-11:30 a.m., Noon Conference or Resident Report from 12:00-1:00 p.m., and Sign-Out Rounds
from 3:00-4:00 p.m. Students accept new admissions with their team every fourth evening (there is no
night call; the night float team starts at 7:00 p.m.), and two days offset from this, every fourth morning
as worked up by night float.
 Work Rounds - They are held each morning from 7:00-9:00 a.m. on weekdays by all members of
Housestaff-Student teams after receiving sign-out at 7:00 a.m. from night float. Students are
expected to pre-round on their patients prior to work rounds.
 Teaching Attending Rounds - Teaching Attending Rounds are held daily from 9:00-11:30 a.m.
Third year students have additional sessions with the attending.
 Conferences - The required conferences are Medical Grand Rounds, Resident Report, Core
Curriculum, Issues in Medicine Series, Morbidity and Mortality Conferences, Clinical Pathological
Conferences and Medicine Clerkship Seminars.
 Grand Rounds - All students are required to attend weekly Medical Grand Rounds on Thursday
mornings at 9:00 a.m. unless they are required to attend a JHH student activity. Internationally
renowned scientists and clinicians will discuss topics relevant to both the practicing clinician as
well as the resident in training.
 Resident Report - Students are required to attend Resident Report held on Tuesdays from 12:00-
1:00 p.m. Admissions from the previous night will be selected and discussion will focus on
management issues using an evidence based medicine format. Additional components include
“Clinical Pearls” presented by selected residents, and a “Picture of Question of the Day” quiz.
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Once a month the session will be a “Medical Jeopardy” competition among the Housestaff-Student
teams with questions based on content covered in prior Resident Report and Noon Conference
sessions.
 Student Lectures - Student sessions are tailored solely for the clerkship students. This series covers
several important topics in clinical medicine, but is not intended as a comprehensive review of all
of internal medicine. Topics have been specifically selected based upon enthusiastic feedback
from students in the past and are coordinated through the JHU Clerkship Directors to complement
those provided to students while at Johns Hopkins Hospital.
 Noon Conference Lecture Series - Noon Conferences are held daily at 12:00 p.m. as per schedule.
In general, the noon lectures are targeted toward resident staff; students, however, have evaluated
the noon conferences very positively, and attendance by students is encouraged unless prevented
by clinical responsibilities. During July and August of each year, the noon conferences are
replaced with the Urgent/Emergent Lecture Series, which orients new housestaff to urgent medical
conditions that they may encounter.
 Core Curriculum and Issues in Medicine Series – This is a subset of Noon Conference lectures that
include resident-led Morbidity & Mortality and Clinical Pathological Conferences, and a
curriculum in Ethics, Research, Nutrition, and the Business of Medicine.
MINI – Clinical Exercise (Mini-CEX)

The Mini-Clinical Exercise (Mini-CEX) is a formative (non-graded) exercise that requires you to be
observed directly by a resident or attending physician interacting briefly with a patient for about 5-10
minutes. The goal of the mini-CEX is for you to have an opportunity to work on developing important
skills and obtain useful feedback on your performance from experienced clinicians.
The domains that are evaluated are: medical interviewing skills, physical examination skills,
professionalism, clinical analysis/judgment, counseling skills, and overall clinical competence. Not all
domains will be part of every Mini-CEX. You should choose to work on areas in which you believe
you can use the most help. You are required to participate in at least 4 mini-CEXs during the course of
the clerkship. You will be given Mini-CEX evaluation forms. Give these to the Attending, Resident,
ACS, Fellow, or Intern working with you to complete after the Mini-CEX.
You are required to bring a minimum of FOUR Mini-CEX forms to the Final Exam to be
eligible to sit for the exam. A Mini-CEX Discharge Instructions Summary Form (which is
distributed at Mid-Point Precede) can count as one of the FOUR required forms.
The Mini-CEX is not a graded exercise. It is a completely formative exercise. While you must
complete the four Mini-CEXs, the evaluation does not get computed into your grade in any way. It is
expected that the “Needs Improvement” category will be used frequently to describe your
performance. A copy of the Mini-CEX form is included in this manual.
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At Hopkins Hospital, it is expected that the Teaching Resident/Teaching Attending member will
participate in the Mini-CEX. At Sinai, the teaching attending or resident, and at JHBMC, the interns,
residents and ward attending will perform the Mini-CEX with you.
Mini CEX – Medicine Core Clerkship

Preceptor Guidelines for Mini CEX
Evaluator: _____________ □Intern □Resident □Fellow □Attending
The mini-clinical evaluation exercise (CEX) focuses on the
Student: ______________________________Date: ____________ core skills that students demonstrate in clinical encounters.
Observation should be approximately 5-10 minutes. Not all
Patient: □ New □ Follow-up □ Random
skills will be observed in all encounters. Mini CEX is
designed to provide students with useful feedback on skills.
1. Medical Interviewing Skills (□ Not observed)
□ Needs Improvement □ Acceptable □ Outstanding
It is not a graded exercise. It is expected that the “Needs
2. Physical Examination Skills (□ Not observed) Improvement” category will be used frequently to describe
□ Needs Improvement □ Acceptable □ Outstanding student performance.
3. Professionalism (□ Not observed)

□ Needs Improvement □ Acceptable □ Outstanding Description of Competencies
Medical Interviewing Skills: Sets up proper environment
4. Clinical Analysis / Judgment (□ Not observed) for interview (e.g. turns off TV), facilitates patients’ telling
□ Needs Improvement □ Acceptable □ Outstanding of story, effectively uses questions/directions to obtain
accurate, adequate information needed; responds
5. Counseling Skills (□ Not observed) appropriately to affect, non-verbal cues.
□ Needs Improvement □ Acceptable □ Outstanding
Physical Examination Skills: Performs maneuvers
6. Overall Clinical Competence (□ Not observed) correctly, follows efficient, logical sequence, informs
□ Needs Improvement □ Acceptable □ Outstanding patients; sensitive to patient’s comfort, modesty.
Time Observing: _____minutes Feedback: Professionalism: Shows respect, compassion, empathy,

_____minutes establishes trust; attends to patient’s needs of comfort,
Main Area to Improve: (Additional comments, if needed on back)
modesty, confidentiality.
_______________________________________________________
_______________________________________________________ Clinical Analysis / Judgment: Develops basic differential

diagnosis/problem list. Selectively
orders/recommends/performs appropriate diagnostic tests,
_______________________________________________________ considers risks, benefits
Counseling Skills: Explains rationale for tests/treatment,

_______________________________________________________ obtains patient’s consent, educates/counsels regarding
management.
_______________________________________________________
Overall Clinical Competence: Demonstrates judgment,
synthesis, caring, effectiveness, efficiency.
_______________________________________________________
_______________________________________________________
14
Clinical Curriculum Duty Hours Policy

Approved Clinical Skills Committee January 18, 2018
The LCME expects that medical schools develop and implement policies and procedures regarding
the amount of time medical students are required to spend in clinical and educational activities during
clerkships.
LCME Element 8.8 Monitoring Student Workload

The medical school faculty committee responsible for the medical curriculum and the program’s
administration and leadership ensure the development and implementation of effective policies and
procedures regarding the amount of time medical students spend in required activities, including the
total number of hours medical students are required to spend in clinical and educational activities
during clerkships.
Attention should be paid to the time commitment required of medical students, especially during the
clinical years. Medical students may voluntarily exceed the duty hours limits based on their motivation
to learn. Medical students should not be pressured to exceed duty hour limits by attending faculty or
residents. However, medical students' hours should be set after taking into account the effects of
fatigue and sleep deprivation on learning, clinical activities, and health and safety.
The Clerkship Directors recognize the implementation of new duty hours rules as of July 1, 2017 may
create a disparity between students and teams.
For the core clinical clerkships, required activities for students will be scheduled according to these
guidelines:
1) No more than 80 hours per week of required activities.
2) A minimum of one day out of seven away from the hospital, off duty, averaged over
four weeks.
3) Clerkships will maintain a goal of 8 hour interval between daily required activities
periods. It is also recognized that medical students may opt to stay in the hospital for
additional educational opportunities, such as discussions with house officers,
observing a unique case, etc. Given the shortened duration of learning in the
discipline that is available to students and the lack of direct patient care decision-
making by students, the committee feels it is reasonable to suspend the “8-hour” rule
when appropriate, and allow 2 additional hours allowed for transitions of care and/or
medical student education.
4) Up to two hours of additional time may be used for activities related to patient safety,
such as providing effective transitions of care, and/or medical student education.
Additional patient care responsibilities must not be assigned to a student during this
time.
5) Night float must occur within the context of the 80-hour and one-day-off-in-seven
requirements.
For advanced clerkships, subinternships and clinical electives, required activities for students will be
scheduled according to these guidelines:
1) No more than 80 hours per week of required activities.
2) A minimum of one day out of seven away from the Hospital, off duty, averaged over
four weeks.
15
3) Night float must occur within the context of the 80-hour and one-day-off-in-seven
requirements.
4) Medical students must be scheduled for in-house call no more frequently than every
third night (when averaged over a four-week period).
5) No more than 24 hours consecutive for clinical activities with 4 additional hours
allowed for transitions of care and/or medical student education.
6) Students must have at least 14 hours free of clinical work and education after 24 hours
of in house call.
You will be required to track your duty hours for a one week period during each half of the quarter to
understand how your time is being spent and to be certain you are not being overworked. We will be
using the New Innovations Duty Hours function to collect this data which is a very easy and time
efficient tool.
Please enter your Duty Hours for a one week period each half of the quarter (dates are provided below). Only record
actual hours you spent in the Hospital. We will not track the time you spend reading or studying at home, commute time,
etc. Please enter this data before the last day of each half of the clerkship. Instructions are provided below for your
convenience. We greatly appreciate your cooperation.
New Innovations Instructions

1. Go to New Innovations
2. Under Work Hours > Log Hours
3. Put the cursor on the cell that represents the first hour worked and drag to the last cell that represents the
hours worked.
Duty Hours data entry is due BEFORE the end of each half.
First Half Second Half
Quarter 1 08/30/2018 – 09/07/2018 09/28/2018 – 10/05/2018
Quarter 2 11/01/2018 – 11/07/2018 11/29/2018 – 12/05/2018
Quarter 3 01/23/2019 - 01/29/2019 02/14/2019-02/20/2019
Quarter 4 04/03/2019 – 04/09/2019 05/01/2019 – 05/07/2019
Quarter 5 06/05-2019 – 06/11/2019 07/03/2019 – 07/09/2019
EXPECTATIONS FOR NIGHTS ON-CALL “LONG CALL” AND FOR

“SHORT CALL” - FAQ
“Who am I on with?”
At Bayview and Sinai, you will be locked into a call schedule with your team. At Johns Hopkins
Hospital, you are expected to take call every 4th night based on the schedule provided at orientation. In
addition, on what would be considered a short call day at Bayview and Sinai, when at Hopkins you
will pick up a patient in the morning that was admitted the previous night by the overnight
16
intern. Once the schedule is set, THERE SHOULD NOT BE SWITCHING OF CALL, except in
urgent situations.
“How often am I on-call and how many patients should I pick up?”
You will be on long call every fourth day with your team at each of the clerkship sites. You are
expected to “pick up” one patient on a call day, perform a full history and physical examination and
formulate a problem list and treatment plan in consultation with the housestaff. You and your
residents may be tempted to wait for a “good” patient to admit. Resist this temptation! All patients
are valuable from an educational standpoint. Waiting for the “good” patient usually only results in a
good deal of waiting. If a “good” patient that interests you is admitted to the hospital in the early
morning hours, after you have gone home, you can always pick up that patient on a post-call day. At
Bayview and Sinai, your team will ensure you receive a fresh admission. At JHH, you should wait
until 8:00 pm for a fresh admission admitted to the firm. Your SAR, firm JAR, and the call Intern can
help you identify these patients. If there is no fresh admission by 8:00, ask the SARs for a patient
admitted by the DATO resident that day. If there are no patients available by 8:00 pm, go home and
pick up a patient the next day admitted by the overnight intern.
“What should I do if patients don’t come in?”

See above for rules at JHH. At Bayview and Sinai, if you are not able to pick up a patient by 8:00 pm
the policy of the clerkship is for you to GO HOME and pick up a patient the following morning.
“What is short call?”

In addition to long call, you will have “short call.” For short call you will also pick up a patient. At
Bayview and Sinai, short call is built into the housestaff schedule. At JHH, you will pick up a patient
admitted the previous night by the overnight intern. You will not be expected to present a new patient
H&P. Thus, at each of the clerkship sites, your 4-day call cycle is as follows: long call, post-long call,
short call, and “good” day (non-admitting).
“Do I need to stay overnight and are there call rooms”

Although the housestaff may encourage you to spend the night in the hospital, this is absolutely NOT a
requirement of the clerkship and, in fact, we strongly recommend that you go home at a more
reasonable hour (by 10:00 p.m.) and read about your patients and get some rest. However, if for some
reason you decide to stay overnight, the call room availability varies by site. Dedicated student call
rooms are available at Sinai Hospital and Bayview. At Hopkins Hospital, in the Medical Student and
Resident Lounge (formerly known as the Doctors’ Lounge), there are call rooms available for
students. The signs on the doors read "Medical Student Call Rooms." There is universal card access
to these areas. These rooms are available on a first come, first serve basis to students on all clinical
rotations.
"When do I get days off?"

At all sites, if a short call day or pre-call day falls on a weekend, then it is expected and accepted that
you will be off on those days. For example, if you are on long call Thursday, post-call Friday, then
Saturday and Sunday, which would be short-call and pre-call days respectively are actually off days.
In addition, if you are on-long call on Saturday, then on the following post-call day, Sunday, students
are not expected to come in to the hospital. This is considered an off day for students to remain in
compliance with school duty hour standards.
17
“What is expected during the Night Shift Block at Johns Hopkins Hospital?”
In September 2014, a night call rotation was implemented at the Johns Hopkins Hospital Site. Each
student rotating at JHH will be required to do a block of nights (4 shifts), unless there is an extenuating
circumstance (must be approved by the Clerkship Directors). Night shift starts at 10 pm and ends
after ACS rounds. You will work directly with the firm intern who is on call overnight. You will get
one admission to be presented at ACS rounds the next morning. When you have downtime, you should
work with the intern to assist with patient cross-cover issues. You should also follow up on patients
previously admitted by you, but are not required to write progress notes for them when you are
working on night shifts. There will be teaching sessions some nights with faculty or senior residents.
If you are done with your admission and there are no other patient issues, you can rest in the call rooms
in the Medical Student Lounge.
You must leave the hospital by 12 pm. Students on night shift will miss afternoon teaching
attending rounds. There will be specially designed teaching sessions at nights. Students will also miss
the noon conference lectures and EKG session with Dr. Petty. The lectures have been video recorded
and are available on Blackboard.
ANY NIGHT FLOAT EXPERIENCES?

See above. There is also an option to spend a week on the night team at Johns Hopkins Bayview, but it
is not required.
THE MEDICINE SERVICE

Your floor team will be composed of:
1. Attending (these may be the same clinical attending for your patients, as with the Assistant Chief
of Service at Hopkins, or several different attendings). At each of the sites, there is also an
additional teaching attending, with whom you will round.
2. Residents. At Hopkins, there are two senior (third year) residents on each team. At Sinai and
Bayview, there may be a junior and a senior resident. They are responsible for teaching on
morning rounds, reviewing your write-ups and presentations, and may also give additional teaching
sessions for the students.
3. Interns. They are the "front line" for patient care, with whom you will work the most closely.
They will help you to choose an appropriate new patient from the admissions for the day, and
supervise any orders and notes that you write. They will be limited in the time available to
formally teach you, but should be able to review the evaluation and care of the patients you share.
4. Nurses. The head nurse or a nurse coordinator may attend morning rounds. Please respect the
nurses; they are the closest and often most attentive observers of the patients, and often have many
years of clinical experience.
5. Case managers. At some of the sites, they may round with your team daily. They will help you
formulate an appropriate discharge plan for your patient. In addition, they have a wealth of
knowledge about community resources and sites of post acute care. Learn as much as you can
from them.
6. Other team members. Your team may also include a social worker, physical/occupational
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therapist, and nutritionist.
WRITE-UPS
You should do a complete write-up on each of the patients you admit. The format is as you learned
during Clinical Foundations of Medicine. Be sure to include a Problem List, and to discuss each of the
active problems under “Assessment and Plan.” The key element that distinguishes the third year
clinical clerk from the second year medical student is the ability to begin to formulate the differential
diagnosis and management plans in the “Assessment and Plan” portion of the write-up. Over the
course of the clerkship, your write-ups should become more streamlined, with increasing emphasis on
developing the assessment and plan.
You should use the blank “Medical Student Note” template at all sites. You absolutely should not be
cutting and pasting text from another person’s note. We also strongly encourage you to exercise
caution if you carry forward information from any of your own notes. Please read it carefully each day
and be sure it is edited with updated information.
WRITING ORDERS
Writing orders is an important part of learning to manage inpatients on the medical service. There are
many sources that describe reasonable ways to write orders. One such framework is described below.
Feel free to adjust this to your own or the specific patient’s needs. A useful acronym for order writing
is: ADC VAAN DIMLS, i.e. Admit, Diagnosis, Condition, Vital signs, Allergies, Activity, Nursing,
Diet, IV fluids, Medications, Labs, and Specials.
Admit
You need to specify the unit or type of unit to which the patient will be admitted. Except for when
you transfer a patient to a different service or unit, in the setting of this clerkship, you will be
admitting your patient to the medical service. You should also specify the specific ward and
identify the physician and specific ward team caring for the patient.
 Example:
Admit to Bayview Medicine, Orange team. Dr. Smith, beeper – 3-1111, intern.
Attending: Dr. Smith
Diagnosis
You need to list a known or working diagnosis. This alerts nurses and other health care providers
to the main issues that are relevant to the care of the patient.
 Example:
Diagnosis: congestive heart failure, R/O myocardial infarction.
Condition
Specify the condition of the patient. Sometimes this is a difficult word or phrase to come up with.
Commonly used terms include good, fair, guarded, critical, and stable. The condition you list for a
patient should in some way parallel the place to which the person is admitted. For instance, it
would probably not be prudent to admit a critically ill patient to a regular ward bed in the absence
of extenuating circumstances.
19
 Example:
Condition: stable.
Vital signs
In this section you detail the frequency and types of vital signs should be obtained for the patient.
Standard vital signs are: heart rate, respiratory rate, blood pressure, temperature, oxygen
saturation, and an admission body weight. Vital signs are usually obtained on an every shift basis.
On a regular medical unit that is every usually every eight hours. You may request more frequent
monitoring; however, the frequency has to be consistent with ward protocol. For most regular
(non-intensive care unit) wards you cannot order vital signs more frequently than every four hours.
If you wish to do it more frequently, you would then probably need to transfer the patient to a more
monitored setting such as an intensive care unit. In addition to regular vital signs, you can
specifically order vital signs such as neurologic checks, orthostatics, and daily weights.
 Example:
Vital signs q 4 hours with orthostatics each morning, daily weights
Allergies
In this section list any drug or nondrug allergies that the patient has to medications, food or other
materials such as latex. The abbreviation NKDA is commonly used for “no known drug allergies.”
If you list an allergy, detail the specific reaction the patient has to the substance
 Example: Allergies: Penicillin leads to hives.
Activity
Specify the permitted activity the patient can do. This is an often over looked section of the orders
and can be a great source of lawyer food. For instance, patients who are not able to walk and are
written for ad lib activity and then walk, fall, fracture a hip, and die make the life of malpractice
lawyers quite easy. You need to be cognizant of this. You may write for orders that specify the
degree of supervision that someone needs, how often they can get up, how they are to get up, and
under what circumstances.
 Examples:
Activity: ad lib
Activity: Out of bed to chair three times a day with supervision only for 2 hours each
time
Nursing
In this section of the orders you can detail additional parameters for nurses to monitor such as
weights, in puts and out puts, orders for Dextrose testing, support stockings, special beds, skin care,
turn and position orders.
 Example:
Nursing: turn and position q 2 hours, dextrose stick bid, apply duoderm to sacral
pressure sore q 3 days.
Diet
Specify an appropriate diet for a patient. You can also specify consistency of food such as solid,
liquid, puree diets. This would also be an appropriate place to write tube feeding orders for
patients who are receiving parenteral oral feedings.
20
 Examples:
Diet: NPO
Diet: ad lib
Diet: no added salt, puree
Diet: 2 gram sodium, low potassium diet, mechanical soft diet
Intravenous fluids
In this section you need to specify the volume and type of intravenous food you want administered
to the patient. For a patient with a heparin lock access for whom no fluids are required, you may
simply specify heparin lock flush q shift.
 Examples:
IV: D5W 100 cc / hr x 3 liters
IV: D5 NS 200 cc / hr x 1 liter, then 100 cc / hr x 2 liters
IV: heplock, flush q shift
Medications
In this section you need to specify drug dose frequency, route and any special instructions for any
drugs required by the patient.
 Example:
Lasix 20 mg po twice daily
Metoprolol XL 50 mg po once daily
Laboratories
In this section of the orders you order laboratory tests often for the next day or for whenever you
would like them drawn.
 Example:
AM labs (date): CBC, BMP, PT/PTT
Special Orders
In this section you can write orders that don’t otherwise fit into another section neatly. Some
people like to put orders for respiratory therapy, notification of physician for various parameters of
vital signs and certain consults such as physical, occupation, speech therapy.
Write a set of admissions orders for every patient you admit to your service. We strongly
recommend writing these orders at the end of your admission note. It is much more important for
you to get into the habit of formulating a set of admission orders than it is for them to actually be
entered into the computer and acted upon by the house staff. When you review your write ups with
your attending or resident, also review the set of orders that you have written.
ORAL PRESENTATIONS
Morning rounds are patient-care-oriented, and the emphasis should be on a concise review of the
history, physical examination, assessment and plan. Mention only those things that are related to the
patient's reason for admission, or that represent significant chronic medical problems. Less is often
more when it comes to presentations. Your ability to present cases well on rounds is critical to your
success in the clerkship.
21
1. Duration should be seven minutes maximum in duration.
2. NEVER present a patient on rounds without having practiced the presentation out loud.
3. Don't read directly from your write-up. Speaking from memory shows that you've incorporated
the material, avoids a sedating monotone presentation, and ingrains in you an organized manner of
presenting patients. Of course, you need not memorize all the details of the presentation, but an index
card with lists of pertinent past medical history, medication, and problems should provide sufficient
prompts for you to remember the critical information.
Every attending has a particular way in which he or she likes a case to be presented. It is
reasonable to ask your attending how they like to have cases presented. The following format is
favored by the Clerkship Directors. In general:
The format for a new patient:

1. Start with a question or focus for your listener – e.g. “I need some help with diagnosis in this
patient,” or “I’d like to focus on management issues in this case.”
2. Lead sentence (chief complaint – does not have to be in patient’s words or stated to create a
mystery), mode of admission of the patient--i.e., ER, from home, transfer from another hospital or
unit)
3. HPI: include the pertinent, past medical history, family and social history and review of systems.
4. Medicines: always report, however, doses may not be relevant
5. Past Medical History: any important chronic medical conditions, significant surgeries, medications
that weren’t included in HPI.
6. Family and Social History: Briefly mention living arrangement, history of substance use.
7. Review of Systems: rarely needed, as pertinent items were incorporated into HPI.
8. Physical Examination: Always include vital signs. Presence or absence of pertinent findings. You
are permitted to say e.g. “the cardiac and pulmonary exams were normal” without detailing each
and every piece of those examinations.
9. Labs relevant to the case
10. Assessment and Plans: This is the most important part of your presentation. Begin with a brief
sentence or two crystallizing entire story. Then provide a problem list. Divide the morass of
clinical information into digestible problems with clear brief titles. This is where you prove to the
listener that you can think about and manage your patient. Start each with “problem # __…” You
need not report every last problem – attendings will read your notes. Within each problem you are
making a case and trying to convince listeners that you know what is going on and that your plans
are well thought out. Within each problem give a condensed argument in a SOAP-like format.
The format for an established patient:

When presenting an established patient, give a brief lead off phrase that can help everyone on the
team remember whom you are discussing, e.g. 45 y.o. man with Wegner’s. Then present the
active problems - state the progress/changes/plans by problem. Be sure you have talked with the
intern caring for the patient, and sometimes the intern who was on-call the previous night, so that
you are up to date.
22
ORAL PRESENTATION PEER ASSESSMENT

In the spirit of helping each other improve skill and learning to provide feedback, you will provide
feedback on each other’s presentations. During the 1st half of the clerkship, you will need to ask one of
the students on your team to complete an assessment form during a presentation of a new patient on
rounds. After rounds, you should discuss the form. You will need to bring this form with you to the
mid-clerkship activities. Forms are available on Blackboard under the “PRECEDE” tab.
PERFORMANCE GOALS AND GRADING POLICY

Your grade for the clerkship is comprised of several components:
 Ward performance (65%)
o Average of scaled numerical ratings from resident, ACS, and attending evaluations
(40%)
o Level of performance on RIME scale based on comments from evaluations (25%)-see
below for details
 NBME exam score (25%)
 Performance on a final standardized patient exercise (10%)
o Includes checklist completed by SP + score on patient note
Students must pass each of these 3 components in order to pass the clerkship.
“All students with disabilities who require accommodations for this course should contact the
Associate Dean for Medical Student Affairs and Divisional Disability Services Coordinator, Dean Tom
Koenig (tkoenig@jhmi.edu or 410-955-3416) at their earliest convenience to discuss their specific
needs. Please note that accommodations are not retroactive. “
Details of individual grade components
I) Clinical evaluations
We describe performance goals in the clerkship using a RIME framework; a progression of Reporter,
Interpreter, Manager, and Educator. Each step is a synthesis of skill, knowledge, and attitudes.1 2 3
Reporter: can work professionally with patients, staff, and colleagues and accurately gather and
clearly communicate the clinical facts on our patient and with the proper terminology (this takes basic
knowledge of what is important, plus the skill, reliability and honesty to do it consistently).
Interpreter: at a basic level, you must identify and prioritize new problems as they arise. The next step
is to offer a differential diagnosis. Success is offering more than one reasonable possibility for new
problems and giving your reasons. (You won’t always have the correct answer.) This step takes
growing knowledge and skill in selecting and understanding clinical facts. Proceeds consistently to
interpreting data. Good working fund of knowledge and active participant in patient care.
1
Herbers JE, et. al. How accurate are faculty evaluations of clinical competence. JGIM 1989;4:202.
2
Marienfelf RD, Reid JC. Six-year documentation of the easy grader in the medical clerkship setting. J Med Edu. 1984;59:589.
3
Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med 1999;74:1203.
23
Manager: this step takes even more knowledge and confidence, plus the skill to select among the
options with your own patient and to be proactive rather than simply reactive. Generally, your
diagnostic plan should include more than one appropriate test option and your therapeutic plan should
consider the merits of all reasonable therapies. Demonstrates skills to select among the options for
patients.
Educator: ultimately, your ability to help patients means an openness to new knowledge and depends
on your skill in identifying questions that can’t be answered from textbooks. Are you able to frame
appropriate clinical questions and cite the evidence that new tests and therapies are worthwhile?
Generally excellent fund of knowledge.
During the clerkship, your goal should be to make the transition from “reporter” to “interpreter” of
clinical information, and evidence of this in narrative comments is required to pass this component.
We guide the faculty and housestaff in assessing how well you have met clerkship goals. Their role is
evaluation of your performance. Faculty and housestaff do not give you a grade, per se; the
responsibility for generating a grade rests with the Clerkship Directors. Attached is a copy of the
evaluation form that is given to the attending, ACS, and senior residents. You may find it useful to use
this form as a guide for a midway assessment of your performance, when you are speaking with your
attending or resident.
It is important to understand that particular attendings and residents have patterns of writing
comments. Some attendings and residents may label each and every student they work with as the
“best” ever, while others are far stricter in their approach to evaluation. The Clerkship Directors have
knowledge of these patterns and this may influence how such ratings contribute to their determination
of your final grade. Trajectory and consistency of performance is also taken into account. It is rare for
a single evaluation to either “make or break” a performance or grade, except when significant issues of
professionalism are at issue.
The Clerkship Directors will review all the narrative comments to determine the level of performance
you achieve based on the RIME framework. Narrative comments must demonstrate substantial
evidence of performance level. Narrative comments are reviewed by each Clerkship Director
independently and then adjudicated together to arrive at a final determination of the RIME
performance.
II) NBME Subject Examination

The NBME Subject Examination is an online version. The paper version will not be offered.
The final exam consists of the National Board of Medical Examiners (NBME) Subject Examination in
Medicine, which is given in the last week of the clerkship. The best way to prepare for the NBME is
to read broadly in internal medicine during the clerkship. Your standard score is the one used to
compute your grade. This score is scaled to have a mean of 74.9 and a standard deviation of 7.8, for a
group of approximately 10,000 first-time takers who took the Medicine Subject Test as a final
clerkship exam following rotations during the 2006-2007 academic year. No one can master all of the
information that is contained in the National Board exam, or predict its exact content. The NBME is
24
scored to compare your performance in a fair, consistent manner with that of others taking it at the end
of their clerkship.
Per School of Medicine policy, all students are required to score above the national 5th percentile in
order to pass a clerkship. For the NBME Medicine exam this means that students must score 59 or
above to pass.
As per School of Medicine policy, a failing grade on the NBME in the setting of marginal clinical
performance will be grounds to fail the course. A failing grade on the NBME in the setting of passing
clinical performance will require remediation of the NBME to pass the course. A failing grade on the
shelf exam, when remediated, will result in a maximum grade of "pass" no matter the clinical
performance. A student who fails the NBME exam may retake the exam an additional 2 times. If the
student does not pass by the 3rd attempt, then they will fail the clerkship and the entire clerkship must
be remediated.
The School of Medicine implemented the following policy on 10/31/2012 for delaying a Summative
Examination/Quiz:
 A student must submit their reasons for delay prior to the summative examination or quiz date
to all of the following:
Danelle Cayea (Course Director, dcayea1@jhmi.edu)
Bruce Leff (Co-Director, bleff@jhmi.edu)
Thomas Koenig (Associate Dean for Students Affairs, tkoenig@jhmi.edu)
 Permission to delay a summative examination or quiz is granted only for exceptional
circumstances (e.g. severe illness, death of a family member).
 The Promotions Committee will receive documentation of any student who has been granted
two or more delays.
 If a summative examination or quiz has been delayed, the section/course director needs to
communicate with the OOC about the need for a makeup. In general re-scheduling a confirmed
make-up time is strongly discouraged.
NBME Self-Assessment Services

The NBME is pleased to announce the expansion of its Self-Assessment Services to include a new
Clinical Science Mastery Series. Built to the same content specifications as the NBME clinical science
subject examinations, this web-based series provides self-assessments for US and international medical
students who want to assess their knowledge of the clinical sciences covered during a clerkship or
medical education course. The material presented in these self-assessments is provided by the NBME
for educational purposes only. There are two, 50-item self-assessments available for each of the
following:
 Clinical Neurology
 Medicine
 Obstetrics/Gynecology
 Pediatrics
 Psychiatry
 Surgery
25
Participants will receive a performance report and a score interpretation guide immediately after
completing a self-assessment. The performance report includes an assessment score, a breakdown of
the number of items answered incorrectly by content category and the opportunity to review
incorrectly answered items. The score interpretation guide includes a conversion table that a participant
can use to “translate” the self-assessment score to an approximate score on the clinical science subject
examination score scale.
Each self-assessment is available for a fee of $20.00. Medical schools and other health organizations
will be able to purchase vouchers for the Clinical Science Mastery Series through the NBME Voucher
Information Program sometime in early 2013.
III) Final Standardized Patient Exercise

The final standardized patient exercise will be similar to the mid-clerkship exercise, but instead you
will see four patients. You will have up to 20 minutes with the patient to take a focused history and
perform a focused physical, and provide any counseling necessary to the patient. Students are acting
as the attending (not a medical student) and you can address yourself as such. Fifteen minutes into the
visit you will hear an intercom signal, which lets you know there are 5 minutes remaining with the
patient. A verbal announcement will indicate the end of the visit. There will be 10 minutes for you to
write a SOAP note outlining your findings, assessment, and plan. Both your score from the encounters
(based on a checklist completed by the SPs noting completion of required elements and interpersonal
skills) and a score from the SOAP notes will count towards your final grade. You must score 50% or
higher to pass this component.
How your final grade is calculated

In order to compare performances across items, students’ scores on each component are converted into
a z-score. These scores are then combined into a final, weighted z-score. A z-score is a type of
standard score, which is a dimensionless quantity derived by subtracting the population mean from an
individual raw score and then dividing the difference by the population standard deviation. This
conversion process is called standardizing or normalizing. The standard score indicates how many
standard deviations an observation is above or below the mean. It allows comparison of observations
from different normal distributions.
The 3-level RIME categorization is converted into a numerical score for purposes of inclusion in the z-
score calculation. Over several years of the clerkship, the modal mean/median performance level is at
the “manager” level. Thus, we convert that performance to a score of “0,” while educator is coded as
1, and reporter/interpreter as -1 as their raw score. Because we are using categorical and not
continuous variables to calculate means and z scores for this item, there are then, by definition, only 3
z-scores a student can receive for this component
The cutoffs for the grades are based on a validated multiyear performance-based assessment of learners
in the medicine clerkship. Thus each student’s individual z-score is compared to a historical mean, and
NOT to other students taking the clerkship at the same time. There is no set distribution of grades,
and, hypothetically, each quarter every single student could score above the cutoff for “honors” and
receive that grade. The cutoffs for honors/high pass/pass were determined by examining z-score
cutpoints that would include students with performance on individual components that reached
criterion for H/HP/P.
26
The z-core cutpoints for grades are:

Honors: 0.5 or above
High Pass: -0.29 to 0.49
Pass: -0.30 to -1.85
Your final grade will be based on your success in meeting the goals of the clerkship in the three major
areas outlined above – knowledge, attitudes, and skills. Passing the course requires passing
requirements in knowledge, attitudes, and skills. A brilliant clinical performance in the technical sense
accompanied by failure in attitudes or professional behavior as reflected in clinical evaluations or any
other means will be grounds to fail the clerkship or receive a grade lower than the one determined by
your final z-score
Any questions about the final grade or the component grades of the clerkship should be directed to the
Clerkship Directors in writing with specific reasons for the grade change. Grade appeals must be
submitted to the Clerkship Directors in writing within 4 weeks after grades are submitted to the
Registrar’s Office. No appeals will be entertained after that point. It is NOT considered academically
acceptable to approach an individual faculty member or house officer and request that an assessment of
your performance be elevated. Such a request will be considered academically unacceptable, and may
be grounds for failing the clerkship and will be brought to the attention of the Academic Promotions
Committee for discussion.
FEEDBACK – Strategies to obtain feedback

At the start of the clerkship or whenever new attending or housestaff join your team, tell them what
your SPECIFIC goals are for the rotation and that you are interested in having them provide you with
feedback on your performance on a regular basis. Then, after you do something, e.g. present a case, do
a procedure, interview a patient, write a set of orders, etc., ask them for feedback on that item. Give
evaluators your write-ups to review and ask for feedback on specific aspects of the history of present
illness or assessment and plan. At the end of the rotation, ask to sit down with your resident and
attending to discuss your performance. When you sit down with them, you should first talk about your
perceptions of your performance and then ask for their feedback. Use the evaluation form to self
assess.
In a personal communication, Dr. Rob Shochet has suggested a framework for thinking about feedback
that we find appealing. He wrote “contemporary thinking about feedback between two people (be they
peers or student-teacher) is that effective feedback derives from a sense of caring about the relationship
and the other person -- wanting them to do well, to be better able to satisfy other's needs, to help them
along their path-- rather than being a simply punitive or judgmental statement. In this way, feedback is
an investment or gift by the provider. Perhaps you've received valuable feedback from peers or
teachers that has felt this way.”
The grade you receive for the clerkship is a summative form of feedback on your performance. It is
critical for you to receive formative feedback during the course of the clerkship to help you improve
your performance. Formative feedback can come from interns, residents, attendings, nurses, patients,
and your fellow students. Faculty and residents are instructed to meet with students at the beginning,
middle, and end of the clerkship to review individual learning goals and to provide ongoing feedback
on your performance. That being said, it is also your responsibility to seek out feedback.
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FROM FORMER VICE DEAN FOR EDUCATION TO CLERKSHIP

DIRECTORS, MEMORANDUM ON THE GRADING SYSTEM
September 10, 2002
Re: Reflections on the Grading System
Dear Course Director,
Last year many members of the academic community at the School of Medicine participated in a wide-
ranging discussion of the meaning of the grading system for medical students. As a result, the
Advisory Board approved a change in the grading system from one with 13 levels to one with 4 levels.
The start of the first academic year under this new system gives me the opportunity to share my
personal philosophy about the grading system and to suggest a possible way of applying it. I do so, in
part, because of the many inquiries I have received about the “desired” grade distribution in the class.
Any opinion or suggestion that follows should be taken as just that. You, as a course director, have the
final authority to award grades. The official description of the new grades, which was approved by the
Educational Policy Committee and is included in the catalogue, is also attached for your files.
Every evaluation system has two potential purposes. The first is to measure the student’s performance
against that of the others in the class. The second is to promote the student’s possibilities for
excellence. The mission statement of the Johns Hopkins School of Medicine, in fact, mandates the
second purpose. There is a creative tension between these two purposes. Last year’s debate about the
grading system grew out of the sense of many applicants that the measurement purpose was the only
one that was important to the faculty.
The new system (H, HP, P, and F) is designed to signal a better balance between the measurement and
possibility by de-emphasizing the former and emphasizing the latter. I believe this redirection of
emphasis is not only desirable, but also safe because the Admissions Committee has the luxury of
choosing among the top 2% of medical school applicants in the United States every year. Surely, such
students should have the intellectual gifts to excel and the School should foster such excellence in
every way possible. In that context, excessive focus on measurement shifts the focus from developing
into an excellent physician to competition for the A- instead of the B+.
In the past you may have noticed that despite your requests that the students not focus on grades, they
did so anyway. The reason for this, in my opinion, is that we did not offer the student a sufficiently
compelling alternative. I think the alternative is to challenge the student to look inward and define for
themselves and in advance why this course or that clerkship will contribute to their excellence as a
(future) physician. We, the faculty, may then join them in this journey toward excellence. If they meet
their own definition, the students should award themselves ‘personal’ honors. In that context, the
grade we award should assume less dominance in their lives. Perhaps our greatest contribution as
educators comes at this point, when we can suggest to the student what they did right, what they could
have done better and how they can reach even further in the next course or clerkship. The School is
trying to make this process easier with on-line evaluation tools such as BlackBoard and E*Value.
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Yet there is still a need for some measurement. “How many students should get honors or high pass,”
is the bottom-line question many of you have presented to me. I do not believe that any student should
feel ashamed with a passing grade from the Johns Hopkins School of Medicine. Our “pass” indicates
that we believe the student has attained sufficient mastery of a challenging curriculum to be entrusted
with the care and life of another human being at some time in the future. When so defined, I believe
most students should earn a “pass” in their courses and clerkships. If you wish to become more
quantitative, I suggest that students who fall within 1 standard deviation around the mean (or perhaps
above the threshold of adequate mastery) should receive a “pass”. This should translate to
approximately 68% of the class. The distribution for the remaining 32% should reflect the fact that the
“honors” grade identifies an exceptional performance beyond what would be expected for an
individual at that level of training. Five – ten percent of the class might qualify for honors, so defined.
This leaves 20-25% who have done very well and exceeds 1 standard deviation from the mean, but
have not excelled beyond their expected level of training.
There may be a few marginal students and the occasional failure. Since these students also come from
the top 2% of the applicant pool, intellectual power is almost never the issue. Psychosocial stresses
almost always are. The greatest service that the course director can carry out on behalf of the student
and the School is to alert Dean Herlong at the earliest possible moment, so that effective academic and
psychosocial intervention can take place before the student fails. The Student Assistance Program
(SAP) serves as a proactive health maintenance tool for the emotional well-being of our students. A
good indicator of when to call Frank is if you are contemplating speaking to the student about his or
her performance. The brilliance of the students and the faculty make for unlimited possibilities in
medical education. I look forward to another challenging year with you.
Sincerely,
David G. Nichols, M.D.
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OASIS/PATIENT TRACKER – Logging Your Patient Encounters During the

Clerkship
As in every core clinical clerkship, we require that you log your patient encounters, using the
OASIS/Patient Tracker system. Logging encounters requires some energy and time on your part, but
we believe strongly that it can enhance your educational experience during this clerkship in at least
three ways:
1. Logging encounters allows you to track your progress toward achieving the learning objectives
of the clerkship. The quantitative criteria, which have been developed by your faculty in this
clerkship, are the clearest way of communicating the clinical learning objectives for this
clerkship. By logging your clinical experience, you can track your progress toward achieving
these learning objectives of this clerkship. This is the essence of the self-directed learner, i.e.,
to reflect on your experience and to seek learning opportunities that help to fulfill your personal
objectives.
2. Tracking one’s learning and professional activity is a professional behavior that will be asked
of you for the remainder of your career. Outstanding clinicians routinely review their clinical
practices in a systematic way that allows them to improve the delivery of care to their patients.
Most licensure, specialty certifications and recertifications require documentation of patient
care experience. Reflecting on and improving one’s practice is a core competency of residency
training programs, referred to as “Practice Based Learning and Improvement.”
3. Logging patient encounters provides the Clerkship Director with the data to compare site and
learning experiences and to improve the clerkship for you and future students. This data is
reviewed not only in this department, but across the entire curriculum, and by national medical
school accreditation bodies such as the LCME.
No clerkship in the JHU SOM curriculum fails a student for not meeting the quantitative criteria for the
clerkship, although each student’s experience is reviewed at the end of the clerkship. Your encounters
will also be reviewed at the midpoint of the clerkship by Clerkship Directors to ensure that no
adjustment in your experience or your approach to learning in the clerkship is needed. The integrity
and timeliness of documentation of your patient encounters may be considered a measure of your
professionalism during this clerkship.
You are required to create a log entry on all patients that you pick up and follow. At a minimum, you
must pick up and follow at least 8 patients during each half of the clerkship.
You are required to pick up and follow a range of patients that will furnish you with core skills, core
areas of patient experience, and core problems, diseases, or conditions.
The core skills are:

1. Caring for patient with new acute condition or exacerbation of a chronic condition
with an emphasis on diagnosis (at least 4 patients)
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2. Caring for patient with new acute condition or exacerbation of a chronic condition
with an emphasis on treatment (at least 4 patients)
3. Caring for patient with a chronic condition (at least 3 patients)
4. Caring for patient with an exacerbation of a chronic condition (at least 2 patients)
5. Caring for patient with a psychosocial issue (at least1 patient)
6. Caring for a patient from a culture not your own (at least 1patient)
7. Caring for an elderly patient (at least 2 patients)
Core problems, diseases, or conditions

You must have experience with at least one patient for each of the problems or diseases / conditions:
anemia, coronary artery disease, chest pain, chronic heart failure, diabetes, dyspnea, electrolyte / acid
base disorder.
Fortunately, for educational purposes, many patients will be able to provide you with experiences in
several of these areas simultaneously. PATIENTS SHOULD BE DOUBLE COUNTED WHEN
APPROPRIATE. If you pick up an elderly patient from a culture not your own with a history of
hypertension, depression, with an exacerbation of chronic heart failure, that you diagnose and treat,
you may, in fact be able to log all of the core skills, a cardiac and geriatrics core area, and several core
problems or diseases.
We have set up a website that is available online to help you log or track your patients and to assess
how the range of patient problems and clinical issues you have encountered during the clerkship. On
average, it should take less than 1 minute for you to enter the data on a patient into the OASIS/Patient
Tracker System.
We advise you to log information on patients that you don’t follow, but who contribute to any
significant learning on any topic in medicine. For example, if you hear a marvelous discussion on
rounds on deep venous thrombosis and you read about this topic, and then entering this in the tracker
system lets you know that you have covered this area during the clerkship.
The diagnoses or symptoms or syndromes listed in the patient tracker system are derived from
discussions among the educational leaders in the Department of Medicine as well as from the
curriculum for medicine clerkships devised by the Clerkship Directors in Internal Medicine, a national
group of Clerkship Directors who have thought long and hard about the appropriate content areas for
medicine clerks.
We advise that you complete your logs on a regular basis. By completing the log in real time, you will
be able to use the system to evaluate gaps in what you have been exposed to and this can help direct
you to pick up certain patients or engage in self-directed reading or learning. Entries must be made
before the end of each half of the quarter.
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All students are required to print out a copy of your OASIS/Patient Tracker Report to be collected by
the Clerkship Directors at the Mid-Clerkship SPE Exam. The Clerkship Directors will review your
Patient Tracker Report to be sure you are on a reasonable trajectory to achieve the targets for the
clerkship. If your log is deficient you will be counseled by the Clerkship Directors and asked to
resubmit your OASIS/Patient Tracker Reports 2 weeks hence. If at that time you require additional
patient experiences to be scheduled, the Clerkship Directors will make those arrangements. You are
also required to bring your final OASIS/Patient Tracker Reports to the final SPE. You will NOT be
able to sit for the mid-clerkship SPE or Final NBME unless you turn in your OASIS/Patient Tracker
Reports. If you have any questions contact the Clerkship Directors.
The instructions for accessing the patient tracking website are:
Using OASIS/Patient Tracker on the Web:
The Training Video is located at: http://oacapps.med.jhmi.edu/bb/Ptrackervid.html
From your desktop, navigate to the Medicine Core Clerkship OASIS/Patient Tracker URL:
https://oasis.med.jhmi.edu/
1. Log-in using your JHED ID.
2. Once you have logged into OASIS, you can view your schedule. If you do not have access to
the application, or if you are missing any clerkships, please contact the Office of Curriculum.
3. Now selection
1. Schedule Tab
2. Medicine Clerkship
3. Requirement Checklist
4. Show Descriptions (to expand Patient Tracker)
5. Enter procedures
6. Select Procedures and add data
4. Using patient data features. Select:

a. Date
b. Site
c. Inpatient or Outpatient
d. Responsibility
e. Patient Identifier
f. Age
g. Ethnicity
h. Feedback (if applicable)
i. Also add entry to (if applicable)
j. Save
5. To print, click on “show,” then “print.”
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New Innovations: Online Evaluations for the Medicine Clerkship

As of October 2001, the Department of Medicine has moved from paper evaluation forms to an online
evaluation system for all Johns Hopkins Hospital clerkship students. This means that your supervising
attendings and housestaff at Johns Hopkins Hospital, Bayview and Sinai will be asked to complete
your clinical evaluations online at the completion of the rotation.
You will also be asked to evaluate your clerkship rotation, supervising house officers and teaching
faculty with online evaluations. Once you have completed your evaluations, you will be able to enter
the system and see the evaluations that have been completed about you. The following text will walk
you through the process of using New Innovations. You are required to complete these evaluations.
New Innovations is a software program with multiple levels of security that uses encryption
technology and multiple levels of security to coordinate the evaluation system.
Where is New Innovations?

From the My JH Home page, select Education, then select New Innovations.
This will log you on using single sign on with your Jhed ID.
How do I know there are evaluations waiting for me?

New Innovations will send you an email message that there are evaluations waiting for you with a
link to the URL.
How do I complete evaluations?

Once you have entered New Innovations, hover over Evaluations on the top tool bar. Select
Complete Evaluations under Manage Evaluations.
All evaluations will appear.
What if New Innovations gives me the wrong evaluation?

You may decline any evaluation that you feel has been incorrectly sent to you. This information will be
sent to the clerkship administrator.
What happens if I don’t complete evaluations?

- New Innovations is programmed to send reminder emails periodically to you if you have not
completed evaluations.
- You will not be able to view your own evaluations until you have completed evaluations.
Who can see evaluations completed about me?

- No other students can see evaluations of students. Residents and teaching faculty can see only
evaluations that they have completed. The following individuals now have access to student
evaluations:
- Dr. Danelle Cayea and Dr. Bruce Leff, Medicine Clerkship students only
- Dr. Thomas Koenig and Dr. Nancy Hueppchen, all students
Who sees the evaluations I complete?
33
- Residents and teaching faculty see only aggregated evaluations. Your name is NOT identified with
any evaluation. Residents and faculty must have been evaluated by at least 4 students before they can
see the aggregated evaluations. Residents and faculty cannot see your identified evaluation of them
until they have completed their evaluation of you and vice versa. This filter is added so that you will
feel confident in being open about your opinions. Please remember, just as we expect residents and
faculty to provide objective and professional evaluations, we also expect the same from students. Dr.
Cayea and Dr. Leff can see evaluations of the clerkship and faculty for the respective clerkships. Dr.
Hueppchen can see evaluations of the clerkships, faculty, and residents.
What are confidential comments?

- Confidential comments are sent immediately by email to Dr. Cayea and the residency program
directors. They are not viewable by any of the individuals above or the person about whom the
comment is made. When these comments have been received in the residency program, they are
considered anonymous. The comments have been used, however, to communicate perceived problems
in the rotations quickly with rotation directors.
What is a mandatory item?

- Some items in evaluations have been identified as mandatory. The evaluations are not completed and
you will not be able to submit them, until you have responded to all mandatory items. Most items have
a “not applicable” choice for these items.
Questions, concerns, problems?

- Under User Menu on the left, the “Help” button provides
STUDENT ATTENDANCE POLICY

Clinical Curriculum Attendance Policy
Approved Clinical Skills Committee January 21, 2010
Approved by the EPCC February 4, 2010
Attendance is required in all required clinical courses. This policy encompasses the following courses, hereafter
referred to as required clinical courses:
 Longitudinal Clerkship
 Transition to the Wards
 PRECEDE
 Transition to Residency and Preparation for Life (TRIPLE)
 Basic Clerkships: Emergency Medicine, Medicine, Neurology, OBGYN, Pediatrics, Psychiatry, and
Surgery
 Advanced Clerkships:
o Chronic Disease and Disability
o Critical Care
o Subinternships in Medicine, Surgery and Pediatrics
Attendance rules are governed by the School of Medicine in the following ways:
1. School Holidays
The School of Medicine publishes an annual calendar that identifies official SOM holidays for students
(http://www.hopkinsmedicine.org/som/students/academics/calendar.html). These holidays currently include
the following:
34
 Labor Day (Quarter 1, 1 day)

 Thanksgiving (Quarter 2, 4 days [2 weekdays, 2 weekend days])
 Christmas and New Year (winter break)
 Martin Luther King Day (Quarter 3, 1 day)
 Spring vacation (spring break)
 Memorial Day (Quarter 4, 1 day)
 Independence Day (Summer Quarter, 1 day)
The holidays which occur during the required clinical course time generally fall on a Monday or Friday
adjacent to a weekend. These weekend days adjacent to these weekday holidays are NOT considered
official school holidays (with the exception of Thanksgiving) and required activities may be scheduled on
those weekend days at the discretion of the course or clerkship director. University Commencement and
Convocation are NOT considered holidays for required clinical course students. Similarly, election day,
presidential inauguration, and other public or civic events are not considered holidays for required clinical
course students.
2. Excused & Unexcused Absences
There are no given ‘personal days’ allowed in a required clinical course. Clarification on what qualifies as
an excused and unexcused absence is as follows:
a). Residency Interviews
The following policy is to address the amount of time that fourth year students can miss from their required
clinical courses for residency interviews. The goal is to ensure that students obtain sufficient experience in
each of the basic disciplines to meet the objectives of the Hopkins curriculum. Interview days should not be
considered the equivalent of PERSONAL days. Students should make every effort to leave as late as
possible and return as early as possible when interviewing to minimize time lost from a core clerkship.
1) On 6-9 week clerkships, students will be allowed to miss 3 full days of responsibilities as excused
absences for interviews.
2) On 4-4.5 week clerkships, students will be allowed to miss 2 full days of responsibilities as excused
absences for interviews.
3) Students must inform course directors of any such absences in advance of the beginning of the
clerkship when possible. If students do not contact the course director in advance of any absences,
they will be considered unexcused and will impact on the student’s final grade.
4) All students who miss more than the allowed days above will be required to develop a plan for
remediation of missed days with the clerkship director. Such remediation is a necessary
requirement for successful graduation from the M.D. curriculum.
b) Comprehensive Clinical Skills Exam (CCSE)
The CCSE is a required educational activity for all graduating medical students. Students are encouraged
not to schedule their CCSE during a required clinical course, but this is not always possible. The student is
to be excused from required clinical course duties for the duration of the exam (approximately 7-9 hours,
since the current 10-case version of the exam runs from about 7AM to 4PM).Students should expect to
attend required clinical course educational activities after they have completed the exam.
c) Other Required Coursework
35
Certain required courses (e.g., Rational Therapeutics) may occasionally be scheduled concurrently with a
required clinical course. If this occurs, scheduled activities for these other courses take priority over all
scheduled required clinical course activities. Nevertheless, if such a conflict arises for a particular student,
remediation may be required (see below).
d) Elective Coursework
Under no circumstances will elective coursework supersede required clinical course activities. Students will
not be excused from required clinical course duties to attend clinical elective courses (or similar activities,
such as research electives or ACLS training), whether such electives are internal or external to Johns
Hopkins SOM. This includes elective experiences requiring complex or expensive travel arrangements, such
as those conducted overseas. It is the responsibility of the student to ensure that no such conflicts
arise. Students should consult the SOM calendar and the Registrar’s office for official start and end dates
for each required clinical course.
e) Personal Reasons (including Religious Holidays)

Students must notify the course or clerkship director as early as possible before the start of the required
clinical course regarding any scheduled absence other than those described above, and should expect that
they will need to make up missed time. This includes (but is not limited to) any absence for religious
holidays, academic events (e.g., presentations at national and scientific meetings, including within Johns
Hopkins), and civic responsibilities (e.g., election day, jury duty). Although each course or clerkship director
has discretion to allow or disallow such absences (except for jury duty and religious holidays, see below*)
based on their potential impact on the educational experience, the general rule is “a day for a day” (i.e.,
each missed day will generally result in one additional day made up at a later time).
Clarifications for specific instances:

1. Since most family events (weddings, family reunions, etc.) are planned for weekends, most of these
events could be attended with minimum time lost from the required clinical courses with advance
planning. However, some personal events (e.g., graduations) typically occur on weekdays. Family
events are excused only when the director has been notified at least 6 weeks prior to the start of the
required clinical course, and when students will not miss more than 2 days (8-week clerkship)/1 day
(4-week clerkship) or any required activities that would be difficult to remediate.
2. Attending JHU School of Medicine Graduation is excused only if a family member or spouse is
graduating.
3. Attendance at a professional meeting for networking or professional development, or to accompany
a family member, during a required clinical course is not excused. Students who are funded by the
Office of Student Affairs or Office for Student Diversity to attend national student association
meetings should follow the 5-step process outlined by the Office for Student Diversity.
*University policy regarding religious holidays states, “Religious holidays are valid reasons to be excused
from class. Students who must miss a class or an examination because of a religious holiday must inform
the instructor as early as possible in order to be excused from class or to make up any work that is missed.”
f) Weather and Other Related Emergencies Within the Baltimore Area
Weather-related policies are stipulated by the Johns Hopkins University and may be found at the URL
below:
http://webapps.jhu.edu/jhuniverse/administration/emergency_weather_security_information/policy_on_unive
rsity_closings/index.cfm
Weather emergencies are available at the phone numbers and website below, as well as on radio and TV
broadcasts (http://www.insidehopkinsmedicine.org/weather.pdf):
36
Baltimore 410-516-7781
Outside Baltimore 800-548-9004
URL: http://webapps.jhu.edu/emergencynotices
Basic Clerkship students are not considered “Required Attendance Employees” and are excused from
attendance at normally-required Clerkship activities if affected by circumstances (e.g., weather) related to
University delays or closings. As necessary, remediation plans will be made on a case-by-case basis by the
Clerkship Director.
g) Weather and Other Related Emergencies Outside the Baltimore Area
Students who travel during (e.g., on weekends) or in close temporal proximity to (e.g., just before) a
required clinical course may be delayed in their return travel plans by inclement weather, flight cancellations,
or other similar events outside their control. In such circumstances, safety is the first priority. Once the
student’s safety is assured, they should immediately notify people related to the course or clerkship, as
appropriate (e.g., course or clerkship director or coordinator, clinical team or preceptor with whom they are
rotating, etc.). Students will generally be required to remediate any time or activities upon safe return or at a
later date. Students should be advised, however, that extended or repeated travel-related absences will be
considered unprofessional behavior and will likely result in grade reductions, failure, or disciplinary action.
h) Illness or Injury (Personal or Family)
Illnesses or injuries are handled on a case by case basis by course or clerkship directors. In almost all
cases, such events cannot be predicted in advance. When either occurs, the student’s first responsibility is
to their own personal safety and the safety and well-being of those around them. Once the situation has
stabilized sufficiently and it is safe to do so, a student should immediately notify people related to the course
or clerkship, as appropriate (e.g., course or clerkship director or coordinator, clinical team or preceptor with
whom they are rotating, etc.). Family emergencies (including illness or death of a loved one) should be
handled similarly. As necessary, remediation plans will be made on a case-by-case basis by the course or
clerkship director.
3. Remediation of Coursework
All absences, even when excused, must be remediated. When it is not feasible to reproduce a clinical or
simulated experience, the course or clerkship director will approve an appropriate remediation. It is at the
discretion of the course or clerkship director to establish a required remediation plan for the student, regardless
of the reason for absence. Note that if a significant component of the educational experience is missed for any
reason, it is at the course or clerkship director’s discretion to require remediation or reduce the student’s
grade.In some cases, students may need to wait for the next available course or clerkship slot for remediation,
potentially delaying promotion or graduation in some circumstances.
4. Consequences of Unexcused Absences
Students who fail to attend required activities (e.g. required clinical course orientation) without advance notice
and are unable to offer a reasonable or appropriate justification (as judged by the course or clerkship director)
may be subject to grade reductions, failure, or disciplinary action on grounds of lack of professionalism.
Unexcused absences, including failure to notify course and clerkship directors about absences in a timely
manner, and failure to remediate when remediation is offered, will impact the evaluation of students in the
following ways: (1) generation of a Professional Concern Card to the Associate Dean of Student Affairs and (2)
a statement attesting to the absence in the narrative evaluation that is forwarded to the Associate Dean of
Student Affairs. This will generally result in grade reductions or failure of the required clinical course or clerkship
for failing to meet the professionalism standard. In the case of clinical clerkships, if students plan to miss more
than 2 days or any required activities that would be difficult to remediate, they should attempt to reschedule the
37
clerkship. However, due to scheduling constraints within the clerkships, this may not be possible. If it is not
possible to reschedule, students must comply with the remediation plan as outlined by the clerkship director.
5. Recourse for Students Who Feel They Have Been Treated Unfairly
Any student who feels unfairly treated with regard to attendance or duty hours policy should discuss these
issues with the course or clerkship director. If a mutually agreeable decision is not reached, the student should
contact the Office of Student Affairs if they wish to pursue the matter further.
PROFESSIONALISM CONCERNS
Starting in Q4/2009-2010, the Dean’s office has instituted the use of professionalism concern cards in
the core clerkships. These cards are intended to help the Dean’s office and Clerkship Directors
identify students who may need extra counseling about or development of their professionalism.
These cards may be completed by Clerkship Directors only and will not be submitted to the Dean’s
office without discussion with a student first. Attendance, dress, assignment completion, interpersonal
difficulties, and issues of honesty are examples of reasons these cards may be submitted.
Professional Behavior Expectations on Clinical Clerkships

Clerkship students are expected to demonstrate professional behaviors as outlined in the JHU SOM
Honor Code and in the AAMC subcompetencies on professionalism:
1. Demonstrate behaviors that show compassion, integrity, and respect for others
2. Demonstrate behaviors that show responsiveness to patient needs that supersedes self-interest
3. Demonstrate behaviors that show respect for patient privacy and autonomy
4. Demonstrate behaviors that show accountability to self, patients, colleagues, the profession, and
society. [Link to Accountability Policy ]
Clerkship directors will communicate discipline specific expectations/tasks for which students will be
held accountable. As with other Clerkship domains such as knowledge and skills, students who
deviate from these expectations, may have their final grade lowered, or the deviation may result
in failure of the clerkship.
Serious breaches of professionalism should be expected to result in failure of the clerkship in which the
breach is detected. These breaches will be handled on a case-by-case basis by the clerkship director.
All such matters will also be referred to the Disciplinary Committee. Examples of such unprofessional
behaviors include but are not limited to: cheating, plagiarism, or other forms of academic dishonesty;
forgery or falsification of documents/records; lying or misrepresentation of facts, figures, or clinical
data; failure to obtain appropriate supervision for clinical care; physical violence, bullying or
harassment against others, or other significant lapses in personal ethical conduct that raise concern
regarding the moral character of the student in question.
INVASIVE PROCEDURES
We will not review the details of the many invasive procedures that may be performed on patients, but
will offer these general guidelines.
1. Becoming an expert in the performance of invasive procedures is not a specific learning

objective of this clerkship. The opportunity to perform procedures may arise. In general,
however, the housestaff perform most of these procedures.
38
2. If you are involved in any procedure where there is any risk of exposure to a patient’s bodily
fluids (blood draw, intravenous access insertion, blood cultures, lumbar puncture, central line
placement, cardiac arrest, paracentesis, thoracentesis, etc.), you MUST WEAR GLOVES and
other protective garments appropriate to the procedure following standard precautions.
3. NEVER RECAP A NEEDLE. Place it in a needle disposal apparatus.
4. NEVER perform a procedure that you do not feel comfortable performing.
5. If you are asked to perform a procedure, ask your intern or resident to supervise you if you do
not feel comfortable performing the procedure.
6. IF YOU EXPERIENCE A NEEDLE STICK INJURY, YOU MUST INFORM YOUR
RESIDENT AND ATTENDING IMMEDIATELY AND GO TO STUDENT HEALTH
SERVICES.
Portions of this manual were adapted from USUHS Department of Medicine third year medicine clerkship handbook, class
2003.
STUDENT INJURY (Occupational Health)

If you are injured during the clerkship, while at work, including by needlestick, inform both
Occupational Health (410-955-6211) and the Clerkship Directors immediately.
ON-LINE RESOURCES
Below are listed a variety of on-line resources that you may find useful during the clerkship.
Orientation to the Hospital and Procedures:

Check out the Intern Survival Guide on the Housestaff’s OslerNet:
http://www.hopkinsmedicine.org/Medicine/oslernet/index.html or through the Dept of Medicine Website
1) Knowledge resources
Textbooks:
- Harrisons Online (available through Welch)
- UptoDate and MDConsult (available from Welch Library)
U.S. Preventive Task Force Guide to Clinical Preventive Services:
http://www.ahrq.gov/clinic/uspstfix.htm
The Cochrane Collaboration Reviews:
http://www.cochrane.org/cochrane-reviews/
Searching for Best Evidence

- Go to the Welch Library home page http://www.welch.jhu.edu/index.cfm and click on “More
frequently used E-resources”. Many of the sites listed here have valuable information. ACP
Pier, Cochrane Library, InfoPOEMS, MDConsult, may help you find relevant studies quickly.
OR-
- http://www.hsl.unc.edu/Services/guides/guides.cfm
This is an excellent introduction to asking and answering evidence based questions.
39
Clinical Practice Guidelines

- The American College of Physicians/ American Society of Internists’ Clinical Efficacy
Assessment Committee reviews and publishes guidelines through the Annals of Internal
Medicine. Past and present guidelines are listed at:
- http://www.acponline.org/clinical_information/guidelines/
- National Guideline Clearinghouse: A searchable index with links maintained by the NIH:
http:// http://www.guidelines.gov/browse/by-topic.aspx
- American College of Cardiology: http://www.acc.org. This is a great resource for published
guidelines on all things cardiac: “unstable angina”, “treatment of congestive heart failure”,
anticoagulation, etc. Read the guideline and the pertinent cited studies for a good understanding
of the therapeutics you see on the wards.
- HIV prevention and treatment: The Johns Hopkins AIDS Service Website:
http://www.hopkinsguides.com/hopkins/ub
2) Skills learning and testing
Knowledge testing: MKSAP for students. Available from ACP-ASIM or CDIM at

www.im.org
USMLE website:
http://http://usmle.org
Both Step 1 and Step 2CK practice questions may be helpful for shelf studying.
Sites which index links to many good learning resources:

http://omni.ac.uk/browse/mesh/a.html
http://www.medicalstudent.com/
Clerkship-specific: Oral presentations, writing an H&P, etc:

Check out suggestions for clerkships at other schools, especially:
-University of Rochester: http://www.urmc.rochester.edu/smd/medicine/imclerk
- Univ.North Dakota:
- http://www.med.und.nodak.edu/depts/intmed/clerkship.html
Urinalysis: Take the University of Utah Laboratory tutorial:

http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html
http://www.labtestsonline.org/
A great site for descriptions of various lab tests and information about performance
characteristics.
Physical Examination Skills
40
Physical exam:
http://www.martindalecenter.com/MedicalClinical_Exams.html#EXAMS-ALL-AD
Links you to other sites with useful videos about performing all parts of the adult exam (has a
section on pediatrics too)
Neuro exam:
http://library.med.utah.edu/neurologicexam/html/home_exam.html
Has great videos of how to perform the neuro exam and cases you can test yourself with.
Heart sounds: Crileys Heart Sounds and Murmurs at Blaufuss. Org

http://www.blaufuss.org/tutorial/#
Pulmonary sounds: THE R.A.L.E. Repository: http://www.rale.ca/Repository.htm
Wondering about the sensitivity/specificity of a given physical finding?

The ACP/ASIM Website has a searchable index of physical findings with an annotated
bibliography: http://www.acponline.org/clinical_information/resources/bedside/ (These references
will wow your resident!)
Dermatology images: University of Iowa:

http://guides.lib.uiowa.edu/content.php?pid=4753&sid=127984
EKG Library/Tutorial:
http://www.ecglibrary.com/
http://library.med.utah.edu/kw/ecg/ecg_outline/
EKG quizzes:
http://www.ecg-quiz.com
X-ray reading:
- “Basic Chest X-ray Review” from Uniformed Services University of Health Sciences
http://rad.usuhs.mil/rad/chest_review/index.html
- “Chest Radiology” from Harvard Medical School

http://eradiology.bidmc.harvard.edu/
http://www.radquiz.com/
A gateway website to other radiology resources, including radiology case of the day.
Case Management
Pulmonary Cases:
http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cases/SELFEV_f.HTM
Nephrology Cases: http://www.globalmednet.com and click on Education and then Nephrology:

the University of Utah’s Internet pathology laboratory for medical education has examples of cases
matched with renal biopsy.
41
Interactive acute renal failure cases:

http://www.ccmtutorials.com/scenarios/renal/index.htm
3) Help with Clinical Management
Clinical Calculators
http://calc.med.edu
http://www.medcalc.com
Pharmacy Database
Most students with handheld PDAs use ePocrates (www.epocrates.com) for drug information
UptoDate is connected with a Drug Information resource as well and can be used to search
medication information.
Patient Education Resources
- Look into clinical practice guidelines above; they usually contain printable patient education
resources.
- Also, Welch Library has a list of electronic patient resources:

http://welch.jhmi.edu/welchone/Consumer-Health-and-Patient-Information
- Searchable patient education links can be found at: http://www.DoctorsPage.net/
- American Association of Family Practitioners has a searchable index of patient education

materials at: http://familydoctor.org/
Mobile Apps (Courtesy of Cheri Smith, Harrison Library):

Sources for medical app ratings and evaluation
All Medical
iMedicalApps http://www.imedicalapps.com (mobile medical app reviews & commentary by
medical professionals. Contains apps grouped by iPhone, Android, iPad, Blackberry)
Epocrates App Directory - app-recommendations/
Students and Residents - http://www.medaholic.com/top-10-iphone-apps-every-medicalstudent-

should-have/
Subsections of General App Directories

iPhone Application List - http://iphoneapplicationlist.com/apps/medical/
AppShopper - http://www.appshopper.com/medical/
42
Best App Ever Awards - http://bestappever.com/awards/2011/winner/medi

Daily App Show – http://dailyappshow.com/category/iphone-apps/medical/
Accessories
TiPb (http://www.tipb.com ) is one of the better sites around if you're looking for an accessory. It's
well organized, making it easy to find the most popular accessories in a variety of categories. It also
includes an online accessory store as well as app reviews, how-tos, forums, and podcasts.
Let us know what you find so it can be added to our list!
4) Shelf exam prep:

http://blogs.welch.jhmi.edu/WelchBlog/content/boardvitals-new-resource#.VZNLTOsYcq8
STUDENT ASSISTANCE PROGRAM

The study of medicine and biomedical science is an exciting, fast-paced and challenging venture. At
one point or another however, every student experiences stress and tension. The Johns Hopkins
University School of Medicine is committed to assisting students in developing these tools to deal with
stress and other troubles when they arise. With goals including optimizing students’ potentials and
easing transitions, the Student Assistance Program (SAP) provides support in dealing with the
pressures and challenges students face during their academic and professional careers.
SAP services are private and confidential, in accordance with state law and University policies. For
more information on the student assistance program, their website may be found at http://jhsap.org/
STUDENT MISTREATMENT POLICY: Guidelines for Conduct in Teacher/Learner

Relationships
I. Statement of Philosophy
The Johns Hopkins University School of Medicine is committed to fostering an environment
that promotes academic and professional success in learners and teachers at all levels. The
achievement of such success is dependent on an environment free of behaviors which can
undermine the important missions of our institution. An atmosphere of mutual respect,
collegiality, fairness, and trust is essential. Although both teachers and learners bear significant
responsibility in creating and maintaining this atmosphere, teachers also bear particular
responsibility with respect to their evaluative roles relative to student work and with respect to
modeling appropriate professional behaviors. Teachers must be ever mindful of this
responsibility in their interactions with their colleagues, their patients, and those whose
education has been entrusted to them.
43
II. Responsibilities in the Teacher/Learner Relationship

A. Responsibilities of teachers (including residents on clinical rotations)
1. Treat all learners with respect and fairness.
2. Treat all learners equally regardless of age, gender, race, ethnicity, national origin,
religion, disability, or sexual orientation.
3. Provide current materials in an effective format for learning.
4. Be on time for didactic, investigational, and clinical encounters.
5. Provide timely feedback with constructive suggestions and opportunities for
improvement/remediation when needed.
B. Responsibilities of learners
1. Treat all fellow learners and teachers with respect and fairness.
2. Treat all fellow learners and teachers equally regardless of age, gender, race,
ethnicity, national origin, religion, disability, or sexual orientation.
3. Commit the time and energy to your studies necessary to achieve the goals and
objectives of each course.
4. Be on time for didactic, investigational, and clinical encounters.
5. Communicate concerns/suggestions about the curriculum, didactic methods,
teachers, or the learning environment in a respectful, professional manner.
Students are advised to review the complete guidelines in the Student Handbook, School of Medicine
catalog or at http://www.hopkinsmedicine.org/som/students/policies/relationships.html
WEATHER ISSUES
In the event of inclement weather, e.g. snowstorm, etc., we follow the University weather emergency
policy. That is, if the University is closed in the event of snow, you are off that day! You may call
410-516-7781 for weather related information.
*Please see more information regarding weather issues under the “Attendance Policy” on page 39.
EMAIL USE
Students are required to use their Hopkins email account (i.e. @jhmi.edu) for ANY AND ALL
Hopkins business. This is required when dealing with both sensitive and non-sensitive information.
This policy includes SENDING email to Hopkins employees. If you are sending information,
sensitive or not, to another employee regarding Hopkins business and you are sending to a third party
email address (ex: @gmail.com, etc) then you are in violation of Hopkins policy. If you need help
connecting a handheld to your Hopkins account please contact 5-HELP.
44

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JOHNS SHOPKINS UNIVERSITY SCHOOL OF MEDICINE

MEDICINE CORE CLERKSHIP HANDBOOK

JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE

MEDICINE CORE CLERKSHIP

Danelle Cayea, MD, MS

Danelle Cayea, MD, MS

600 N. Wolfe Street, Nelson/Harvey Bldg

Goals And Objectives Of The Clerkship ........................................................................... 4

2. Expand and integrate your fund of knowledge in medicine;

3. Improve your history-taking and physical examination skills;

4. Improve your oral case presentation skills;

GOALS AND OBJECTIVES OF THE CLERKSHIP

By the end of the clerkship the student should:

1. Demonstrate professional behaviors including reliability and commitment, response to

3. Be able to demonstrate communication behaviors to accomplish the three functions of the

4. Perform a complete and accurate history and physical examination.

5. Obtain and interpret basic laboratory test results.

1. Definition of the syndrome or disease

HOW TO SUCCEED ON THE CLERKSHIP

1. Exhibit respect for your patients and coworkers at all times.

9. Read about your patients' problems.

Johns Hopkins Bayview Medical Center:

 Subspecialty Conferences - Subspecialty conferences in Pulmonary Medicine, Cardiology and

Team-specific resident goals:

Johns Hopkins Hospital:

MINI – Clinical Exercise (Mini-CEX)

Mini CEX – Medicine Core Clerkship

3. Professionalism (□ Not observed)

Time Observing: _____minutes Feedback: Professionalism: Shows respect, compassion, empathy,

_______________________________________________________ Clinical Analysis / Judgment: Develops basic differential

Counseling Skills: Explains rationale for tests/treatment,

Clinical Curriculum Duty Hours Policy

LCME Element 8.8 Monitoring Student Workload

New Innovations Instructions

2. Under Work Hours > Log Hours

EXPECTATIONS FOR NIGHTS ON-CALL “LONG CALL” AND FOR

“What should I do if patients don’t come in?”

“What is short call?”

“Do I need to stay overnight and are there call rooms”

"When do I get days off?"

ANY NIGHT FLOAT EXPERIENCES?

THE MEDICINE SERVICE

therapist, and nutritionist.

1. Duration should be seven minutes maximum in duration.

The format for a new patient:

The format for an established patient:

ORAL PRESENTATION PEER ASSESSMENT

PERFORMANCE GOALS AND GRADING POLICY

Details of individual grade components

II) NBME Subject Examination

NBME Self-Assessment Services

III) Final Standardized Patient Exercise

How your final grade is calculated

The z-core cutpoints for grades are:

FEEDBACK – Strategies to obtain feedback

FROM FORMER VICE DEAN FOR EDUCATION TO CLERKSHIP

Dear Course Director,

OASIS/PATIENT TRACKER – Logging Your Patient Encounters During the

The core skills are:

3. Caring for patient with a chronic condition (at least 3 patients)

5. Caring for patient with a psychosocial issue (at least1 patient)

7. Caring for an elderly patient (at least 2 patients)

Core problems, diseases, or conditions