Fourth Year Pediatric Clerkship Learning Objectives

EPAs & Functions

The Department’s expectations of your performance are aligned with the College of Medicine’s Entrustable Professional Activities (EPA) based-curriculum. You will experience, be taught, and evaluated specifically on your performance of the following EPAs.

EPAs

1. Gather a history and perform a physical examination
2. Prioritize a differential diagnosis following a clinical encounter
3. Recommend and interpret common diagnostic and screening tests
4. Enter and discuss orders and prescriptions
5. Document a clinical encounter in the patient record
6. Provide an oral presentation of a clinical encounter
7. Form clinical questions and retrieve evidence to advance patient care
8. Give or receive a patient handover to transition care responsibility
9. Collaborate as a member of an interprofessional team
10. Recognize a patient requiring urgent or emergent care and initiate evaluation and management
11. Obtain informed consent for tests and/or procedures
12. Perform general procedures of a physician
13. Identify system failures and contribute to a culture of safety and improvement

Functions

Gather a history and perform a physical examination

• Obtain a complete and accurate history in an organized fashion.
• Demonstrate patient-centered interview skills (attentive to patient verbal and nonverbal cues, patient/family culture, social determinants of health, need for interpretive or adaptive services; seeks conceptual context of illness; approaches the patient holistically and demonstrates active listening skills).
• Identify pertinent history elements in common presenting situations, symptoms, complaints, and disease states (acute and chronic).
• Obtain focused, pertinent histories in urgent, emergent, and consultative settings.
• Consider cultural and other factors that may influence the patient’s description of symptoms.
• Identify and use alternate sources of information to obtain history when needed, including but not limited to family members, primary care physicians, living facility, and pharmacy staff.
• Demonstrate clin
• Perform a complete and accurate physical exam in logical and fluid sequence.
• Perform a clinically relevant, focused physical exam pertinent to the setting and purpose of the patient visit.
• Identify, describe, and document abnormal physical exam findings.
• Demonstrate patient-centered examination techniques that reflect respect for patient privacy, comfort, and safety (e.g., explaining physical exam maneuvers, telling the patient what one is doing at each step, keeping patients covered during the examination). ical reasoning in gathering focused information relevant to a patient’s care.
• Demonstrate cultural awareness and humility (for example, by recognizing that one’s own cultural models may be different from others) and awareness of potential for bias (conscious and unconscious) in interactions with patients.
• Perform a complete and accurate physical exam in logical and fluid sequence.
• Perform a clinically relevant, focused physical exam pertinent to the setting and purpose of the patient visit.
• Identify, describe, and document abnormal physical exam findings.
• Demonstrate patient-centered examination techniques that reflect respect for patient privacy, comfort, and safety (e.g., explaining physical exam maneuvers, telling the patient what one is doing at each step, keeping patients covered during the examination).

Prioritize a differential diagnosis following a clinical encounter

• Synthesize essential information from the previous records, history, physical exam, and initial diagnostic evaluations.
• Integrate information as it emerges to continuously update differential diagnosis.
• Integrate the scientific foundations of medicine with clinical reasoning skills to develop a differential diagnosis and a working diagnosis.
• Engage with supervisors and team members for endorsement and verification of the working diagnosis in developing a management plan.
• Explain and document the clinical reasoning that led to the working diagnosis in a manner that is transparent to all members of the health care team.
• Manage ambiguity in a differential diagnosis for self and patient and respond openly to questions and challenges from patients and other members of the health care team.

Recommend and interpret common diagnostic and screening tests

• Recommend first-line, cost-effective diagnostic evaluation for a patient with an acute or chronic common disorder or as part of routine health maintenance.
• Provide a rationale for the decision to order the test.
• Incorporate cost awareness and principles of cost-effectiveness and pre-test/post-test probability in developing diagnostic plans.
• Interpret the results of basic diagnostic studies (both lab and imaging); know common lab values (e.g., electrolytes).
• Understand the implications and urgency of an abnormal result and seek assistance for interpretation as needed.
• Elicit and take into account patient preferences in making recommendations.

Enter and discuss orders and prescriptions

• Demonstrate an understanding of the patient’s current condition and preferences that will underpin the orders being provided.
• Demonstrate working knowledge of the protocol by which orders will be processed in the environment in which they are placing the orders.
• Compose orders efficiently and effectively, such as by identifying the correct admission order set, selecting the correct fluid and electrolyte replacement orders, and recognizing the needs for deviations from standard order sets.
• Compose prescriptions in verbal, written, and electronic formats.
• Recognize and avoid errors by using safety alerts (e.g., drug-drug interactions) and information resources to place the correct order and maximize therapeutic benefit and safety for patients.
• Attend to patient-specific factors such as age, weight, allergies, pharmacogenetics, and co-morbid conditions when writing or entering prescriptions or orders.
• Discuss the planned orders and prescriptions (e.g., indications, risks) with patients and families and use a nonjudgmental approach to elicit health beliefs that may influence the patient’s comfort with orders and prescriptions.

Document a clinical encounter in the patient record

• Filter, organize, and prioritize information.
• Synthesize information into a cogent narrative.
• Record a problem list, working and differential diagnosis and plan.
• Choose the information that requires emphasis in the documentation based on its purpose (e.g., Emergency Department visit, clinic visit, admission History and Physical Examination).
• Comply with requirements and regulations regarding documentation in the medical record.
• Verify the authenticity and origin of the information recorded in the documentation (e.g., avoids blind copying and pasting).
• Record documentation so that it is timely and legible.
• Accurately document the reasoning supporting the decision making in the clinical encounter for any reader (e.g., consultants, other health care professionals, patients and families, auditors).
• Document patient preferences to allow their incorporation into clinical decision making.

Provide an oral presentation of a clinical encounter

• Present information that has been personally gathered or verified, acknowledging any areas of uncertainty.
• Provide an accurate, concise, and well-organized oral presentation.
• Adjust the oral presentation to meet the needs of the receiver of the information.
• Assure closed-loop communication between the presenter and receiver of the information to ensure that both parties have a shared understanding of the patient’s condition and needs.

Form clinical questions and retrieve evidence to advance patient care

• Develop a well-formed, focused, pertinent clinical question based on clinical scenarios or real-time patient care.
• Demonstrate basic awareness and early skills in appraisal of both the sources and content of medical information using accepted criteria.
• Identify and demonstrate the use of information technology to access accurate and reliable online medical information.
• Demonstrate basic awareness and early skills in assessing applicability/ generalizability of evidence and published studies to specific patients.
• Demonstrate curiosity, objectivity, and the use of scientific reasoning in acquisition of knowledge and application to patient care.
• Apply the primary findings of one’s information search to an individual patient or panel of patients.
• Communicate one’s findings to the health care team (including the patient/family).
• Close the loop through reflection on the process and the outcome for the patient.

Give or receive a patient handover to transition care responsibility

• Conduct handover communication that minimizes known threats to transitions of care (e.g., by ensuring you engage the listener, avoiding distractions).
• Document—and update—an electronic handover tool.
• Follow a structured handover template for verbal communication.
• Provide succinct verbal communication that conveys, at a minimum, illness severity, situation awareness, action planning, and contingency planning.
• Elicit feedback about the most recent handover communication when assuming primary responsibility of the patients.
• Demonstrate respect for patient privacy and confidentiality.
• Provide feedback to transmitter to ensure informational needs are met.
• Ask clarifying questions.
• Repeat back to ensure closed-loop communication.
• Ensure that the health care team (including patient/family) knows that the transition of responsibility has occurred.
• Assume full responsibility for required care during one’s entire care encounter.
• Demonstrate respect for patient privacy and confidentiality.

Collaborate as a member of an interprofessional team

• Identify team members’ roles and the responsibilities associated with each role.
• Establish and maintain a climate of mutual respect, dignity, integrity, and trust.
• Communicate with respect for and appreciation of team members and include them in all relevant information exchange.
• Use attentive listening skills when communicating with team members.
• Adjust communication content and style to align with team-member communication needs.
• Understand one’s own roles and personal limits as an individual provider and seek help from the other members of the team to optimize health care delivery.
• Help team members in need.
• Prioritize team needs over personal needs in order to optimize delivery of care.

Recognize a patient requiring urgent or emergent care and initiate evaluation and management

• Recognize normal vital signs and variations that might be expected based on patient- and disease-specific factors.
• Recognize severity of a patient’s illness and indications for escalating care.
• Identify potential underlying etiologies of the patient’s decompensation.
• Apply basic and advanced life support as indicated.
• Start initial care plan for the decompensating patient.
• Engage team members required for immediate response, continued decision making, and necessary follow-up to optimize patient outcomes.
• Understand how to initiate a code response and participate as a team member.
• Communicate the situation to responding team members.
• Document patient assessments and necessary interventions in the medical record.
• Update family members to explain patient’s status and escalation-of-care plans.
• Clarify patient’s goals of care upon recognition of deterioration (e.g., DNR, DNI, comfort care).

Obtain informed consent for tests and/or procedures

• Describes the indications, risks, benefits, alternatives, and potential complications of the procedure.
• Communicates with the patient/family and ensures their understanding of the indications, risks, benefits, alternatives, and potential complications.
• Creates a context that encourages the patient/family to ask questions.
• Enlists interpretive services when necessary.
• Documents the discussion and the informed consent appropriately in the health record.
• Displays an appropriate balance of confidence with knowledge and skills that puts patients and families at ease.
• Understands personal limitations and seeks help when needed.

Perform general procedures of a physician

• Demonstrate the technical (motor) skills required for the procedure.
• Understand and explain the anatomy, physiology, indications, risks, contraindications, benefits, alternatives, and potential complications of the procedure.
• Communicate with the patient/family to ensure pre- and post-procedure explanation and instructions.
• Manage post-procedure complications.
• Demonstrate confidence that puts patients and families at ease.

Identify system failures and contribute to a culture of safety and improvement

• Understand systems and their vulnerabilities.
• Identify actual and potential (“near miss”) errors in care.
• “Speak up” in the face of real or potential errors.
• Use system mechanisms for reporting errors (e.g., event reporting systems, chain of command policies).
• Recognize the use of “workarounds” as an opportunity to improve the system.
• Participate in system improvement activities in the context of rotations or learning experiences (e.g., rapidcycle change using plan-do-study-act cycles; root cause analyses; morbidity and mortality conferences; failure modes and effects analyses; improvement projects).
• Engage in daily safety habits (e.g., universal precautions, hand washing, time-outs).
• Admit one’s own errors, reflect on one’s contribution, and develop an improvement plan.