Tutorials

Clinical tutorials gives you the opportunity to apply the skills you learned in HxPxDx on real patients. You will do a complete history and physical on 6 patients; 2 at Carle, 2 at Provena, and 2 at the Danville VA Hospital.

Tutorials start around the time of your HxPxDx physical exam final. Here's how it works:

Rotation Assignments

Debra will put out a sign up sheet sometime during the first half of the spring semester, and students will sign up for their desired meeting times.You are required to sign up for one rotation at each site (Carle, Provena, VA). The time you sign up for is a meeting time only - you see patients on your own time (see below). Tutors frequently make adjustments to the schedule, so don't get too attached to the time you signed up for.

Typically, there are 4 students per tutorial group, but if there are too many students, then groups will be allowed to expand to 5. Debra WILL enforce this rule, so don't try anything funny with the sign up sheets. Of course if there are too few students, then groups of 3 will be allowed.

Who are the tutors?

Tutors are typically MD's who volunteer their time to teach you. A few of the tutors are M4 students who have done very well in their clerkships.

Student responsibilities during each rotation

Here is what you will actually do during each rotation:

Debra will contact you prior to the first scheduled meeting of the rotation and tell you who your tutor is and when/where to meet your tutor. At your first meeting, your tutor will orient you to how he/she will run the rotation and what he/she expects from you. Often, during the first meeting, tutors will take their group to a patient bedside for teaching purposes. After this first meeting, you are free to find a patient at any time. Subsequent meetings will entail 1-2 students presenting patients they have seen (depending on whether they are "long" or "short" presentations - you will work the schedule out with your tutor during the first meeting).

When you see a patient, you will do a complete history and physical (as taught in the HxPxDx course) and write up the patient (example write up provided). When it is your turn to present, you will present the patient to your group and turn in the write up to your tutor. Each tutor has a different style, but most will have you start by providing the chief complaint and having the group come up with a differential diagnosis based solely on the chief complaint. You will then proceed with HPI, PMH, FH, SH, ROS, etc., with your tutor moderating the session and providing feedback/teaching as appropriate.

Some tutors will also assign brief learning objectives for students to present, so be aware that there may be some additional work beyond seeing patients and doing write-ups.

There are 10 scheduled meetings for each rotation, but it is possible to finish in less than 10 sessions, depending on the number of students in the group and how your tutor runs things..

How to find a good patient

The easiest way to find a patient is to ask the nurses at the nurses station or find an upperclassman or resident. However, many nurses are not familiar with what you are required to do and thus may not give you a good patient. Be sure to tell the nurse you are a second year medical student looking for a good patient who would be willing to let you perform a complete history and physical exam, which takes approximately 2 hours. They will usually direct you to a good patient. The M3s and M4s are familiar with what you have to do, so they are a helpful resource. The residents in IM are also very helpful if you explain as above. If in the first few minutes you do not feel the patient is cooperative, just conclude the interview politely and go find another paitent. Even a cooperative patient gets tired of things toward the end of 2 hours, so don't try to push through with an uncooperative patient.

Other ways to find a good patient are to find out which M3 students are working at your site and have them direct you to patients. Advance notice is better for this approach, so that they have time to find someone for you.

At the VA, you will most likely be given one of your tutor's patients. If possible, ask them for 1 or 2 backups in case people say no. If a patient is hesitant, do not try to talk them into it - it makes for a difficult PE and a bad write up.

Tutor responsibilities

In addition to moderating the sessions as described above, your tutor will grade your write up and hand it back to you. You are required to give the graded copy to Debra. Tutors also complete a mid-rotation and an end rotation evaluation for each student. The criteria on which you are being evaluated are found on the HxPxDx important documents page.

OSCEs

Three clinical exams are also required for tutorials. These are called "Objective structured clinical exams" (OSCEs). The first 2 are not graded. The third counts toward your Tutorials grade. You must complete all 3 OSCEs or you will fail Tutorials. During each OSCE, you will conduct a focused history and physical on a standardized patient. You only have about 10 minutes for the history and 10 minutes for the physical. This task requires you to focus only on the history and physical exam pertinent to your patient's chief complaint. For an M2 student, this is difficult to do at first, because you are used to doing the FULL H&P. Thus, the first 2 OSCEs are not graded, but there is a senior student or MD observing you to give you feedback so that you will be ready for the 3rd OSCE.

Grades

Grades are based on your tutor evaluations and the 3rd OSCE. You are REQUIRED to attend all Tutorials sessions and OSCEs. Of course, you can get an excused absence for health or emergency reasons, but usually this will require that a make up assignment be completed.

A few tips

There may be high demand for afternoon meeting times over evenings, but keep in mind that afternoon is the prime time to see patients.

Write ups typically take 4-6 hours. It is important to be thorough, precise, and concise (this is what your tutor uses to evaluate you).

You are evaluated on your group interactions and on your skills of creating a differential diagnossis and asking pertinent questions about the patient. When it is your turn to add to the differential diagnosis, it is best to list all the horses before the zebras unless you really think it is a zebra diagnosis. Be prepared for your tutor to challenge your differential diagnosis. Try to list the next most likely thing when it is your turn (this is a skill that comes with practice and time).