SOM 8: Core Clinical Competencies CORE CLINICAL COMPETENCIES Upon graduation, we expect our students to demonstrate competency in four general areas: (1) professional behavior, (2) clinical skills, (3) medical content knowledge, and (4) addressing family and societal influences in health care delivery. I. PROFESSIONAL BEHAVIOR Communication to Patients and the Health Care Team The student will demonstrate the importance of, and skill in producing and handling confidentially and appropriately, oral and written communication with and to patients, colleagues, and the community by doing the following: 1. Discussing physician, patient, and family factors (including patients' hidden agendas) which contribute to difficult physician/patient/family relationships and demonstrating interpersonal skills that will enhance communication between the physician and the patient and his/her family. 2. Explaining how communication with patients, family, and community may differ in rural health care settings and other cultural/ethnic settings. 3. Professionally and compassionately relating news of a serious acute or chronic illness or a congenital abnormality to patients and their families. 4. Identifying, organizing, and recording accurately in the problem-oriented patient record (paper or paperless) the information needed to appropriately address the patient's problem/condition. 5. Utilizing the existing medical information to prepare appropriate and meaningful follow-up and consultation notes. 6. Explaining the roles of primary care and subspecialists in the overall care of patients, including the responsibilities of the primary care physician for coordination of patient care during consultation and referral. 7. Working and communicating effectively and professionally with the health care team, colleagues, consultants and agencies, patients’ employers, and the patient and family. Self-education The student will demonstrate skills of acquiring and managing medical information by doing the following: 1. For a variety of medical problems, identifying key information sources and methods for accessing them. 2. Conducting a literature search using an online database. 3. Assessing the quality of a medical study by describing its weaknesses, limitations, and application to clinical practice. 4. Accessing medical information using online information sources, including, but not limited to the Internet and World Wide Web. 5. Utilizing drug, other databases and decision support systems. 6. Skillfully managing information obtained from a variety of sources by a variety of methods. 7. Understanding the use of telemedicine. Ethical Issues and Professionalism The student will demonstrate an understanding and appreciation of ethical issues which are essential to professional delivery of patient care by doing the following: 1. Developing a productive interaction with patients by valuing the patient and his/her input, encouraging patient autonomy on the basis of informed choices under the guidelines of informed consent, maintaining confidentiality of patient information, and maintaining continuing personal responsibility for the patient's (and family's) health care. 2. Describing the professional and ethical issues facing physicians when encountering and treating the economically disadvantaged (poor, lack of health care insurance, homeless, Medicaid, Medicare). 3. Describing the professional and ethical issues facing physicians under traditional fee-for-service and managed care systems in life and death decisions (brain death and vegetative states) and weighing the needs of patients v. society. 4. Identifying and presenting in an unbiased manner potentially controversial health care issues, including (1) Reproductive choice, (2) Maternal-fetal conflicts, (3) Religious conflicts with provider, and (4) medical team conflicts. 5. Recognizing and helping in physician impairment (drug, alcohol, psychological, family problems). II. CLINICAL SKILLS Basic Skills Interviewing, History, Physical Examination The student will demonstrate at least a basic level of competence in the skills--medical interviewing, history-taking, physical examination, and information organizing and recording-- which are essential to recognition, definition, and management of the wide spectrum of problems seen in the practice of primary care medicine. In addition to overall competence in the above- mentioned skills, the student must be able to obtain, organize, and record information on the following specific topics: 1. History: A. Developmental screening and childhood growth patterns (height, weight, and head circumference) B. Psychiatric history C. Sexual history and, for women, menstrual and obstetrical history D. Family history as it relates to risk factors for disease and possible congenital anomalies/risks E. Screening/history for frequently overlooked problems including behavioral problems in children/adolescents, bleeding disorders, and sleep disorders 2. Exam: A. Complete physical exam including: (1) Cardiovascular exam (including peripheral vascular examination) (2) Pulmonary exam (3) Abdominal exam (4) Genito-urinary/gynecological exam (5) Neurologic examination, including funduscopic examination (6) Musculoskeletal exam (especially patient with injured major joint) (7) Head and neck examination (8) Skin examination (9) Breast exam (10) Mini mental status exam of cognitive functioning B. Special examinations 1. Obstetrical examination 2. Well or ill newborn examination, including state of hydration 3. Geriatric examination, including mentation and state of hydration Diagnostic Skills The student will demonstrate an understanding of the need for and an ability to make basic diagnostic and treatment decisions on the basis of appropriate (but limited) clinical data by (1) formulating a differential diagnosis using history and physical exam data, (2) developing a prioritized problem list, (3) applying principles of sensitivity, specificity, pre-test predictive values and cost considerations in selecting tests, (4) interpreting test results, (5) making diagnostic- decisions, (6) initiating appropriate consultation/referral when needed and (7) developing a treatment plan that responds to the ongoing changes in patients and their illnesses. The student will also utilize appropriate information resources to assist with the diagnostic process. In addition, the student will demonstrate knowledge of what they measure, indications, and how to interpret the following: 1. Blood tests (Complete blood count; blood smear; chemistry panels; arterial blood gas; lipid profiles; 2. Tests using other bodily samples (urinalysis; body fluid cell counts; lumbar puncture; Pap smear; pregnancy test; peritoneal lavage); 3. Imaging studies (Chest X-ray; plain abdominal X-ray; Abdominal x-rays with contrast [upper GI series; Barium enema; IVP; cholecystogram], ultrasound including pregnancy-related diagnoses) CT/MRI; other special imaging studies [mammography; Nuclear medicine studies arteriography]); 4. Physiological tests (pulmonary function tests; ECG; EEG/EMG/evoked response); 5. Tests for evaluation of neuropsychiatric symptoms (neuropsychological testing and psychological evaluations including personality tests and inventories) and organize all data using the five axes of the DSM-IV. Screening and Health Maintenance The student will demonstrate both understanding of screening and health maintenance for individuals and families by doing the following: 1. Identifying health risks in patients, families, and communities using probability estimates of disease prevalence specific to the geographic and socioeconomic community of the practice location and natural history of common problems and illnesses over the course of the individual and family life cycles and using this information for health supervision based on age and environment. 2. Demonstrating basic knowledge for selecting protocols and strategies for risk factor modification in patients, families, and communities. 3. Using appropriate screening tools and protocols for health maintenance in specific populations and age groups, including encouraging patients seen for episodic or acute illness to seek continuing medical care and identifying appropriate indications and schedules for preventive screening, health maintenance activities. 4. More specifically, the student will demonstrate knowledge and skills on the following topics: A. Risk factors for common chronic illnesses, such as stroke, hypertension, cancer, heart disease, diabetes. B. Indications and interpretation of periodic screening tests including the impact of age, gender, ethnicity and other risk factors. C. Routine prenatal care and deviations from the routine, anticipated course. D. Use and interpretation of tests for neonatal screening, developmental screening, hearing and vision screening, lead screening, and drug screening in the infant and child. E. The impact of life style choices (e.g., nutrition, exercise, sexuality, substance use and abuse) on health and disease. F. Principles of guidance/intervention for moderation of life style choices, age appropriate behavioral concerns, puberty, injury prevention and home safety. G. Appropriate immunizations and their side effects for infants, children about to enter school, adolescents, adults, and the elderly. Pharmacology and Therapeutics The student will demonstrate an understanding of the basic principles of pharmacologic management of common disorders, use critical pathways, when appropriate, to design basic treatment programs. The student also needs to do the following 1. Specify the effects of drugs and toxic agents on the nervous system, including the drugs used to treat neurological conditions themselves. 2. Identify pharmacokinetics and volume distribution of medications in the pregnant woman, utilize the pregnancy classification system in the PDR to select drugs, including certain drugs and environmental agents that may be teratogenic. 3. Calculate a drug dose for infants, prepubertal children, and the geriatric population. 4. List the most common generic types of medications used for management of each of the following uncomplicated conditions: Otitis media, Wheezing, Conjunctivitis, Allergic rhinitis, Urinary tract infection, Impetigo, Eczema, Fever, Streptococcal pharyngitis, Acne, Bronchitis/ Pneumonia, Sinusitis. 5. Summarize the indications, basic mechanisms of action, common side effects, and drug interactions of the following classes of psychotropic medications: anxiolytics, antidepressants, antipsychotics, lithium, anticonvulsants, anticholinergics, beta blockers and stimulants. 6. Identify the basic pharmacology of analgesic and anesthetic agents. 7. Write a prescription and check for interactions using drug database programs. Patient Education The student will demonstrate an understanding of, appreciation for, and skill in patient education as means to involve patients in decision-making, enable and encourage them to accept personal responsibility for their own actions regarding their health care, and elicit behavioral compliance. The student will also describe the role of the primary care physician and other members of the health care team in patient education and health promotion in, but not limited to, the following general areas: 1. Injury Prevention: Seat belt use: Domestic violence/child abuse; Home safety 2. Prevention/Health Screening: Breast self-exam, mammograms, Pap smears; Testicular self- exam, prostrate screening protocol, colon cancer screening, risk factors for cardiovascular disease and cerebrovascular disease 3. Hospital discharge education: Postpartum care, breastfeeding, wound care, use of medications, activity restrictions 4. Chronic conditions including chronic or recurrent pain syndromes Technical Skills In addition to understanding when they are appropriate, the student will demonstrate the ability to perform, using sterile technique when indicated, the following common technical skills: 1. Suture a simple laceration with interrupted sutures. 2. Insert a nasogastric tube and confirm appropriate placement. 3. Place a peripheral IV. 4. Place and remove skin staples. 5. Establish an adequate airway. 6. Perform basic CPR for adult and child. 7. Demonstrate surgical scrub techniques. 8. Perform vaginal delivery. 9. Perform venipuncture and arterial puncture, including arterial blood gases. 10. Perform lumbar puncture. 11. Obtain Pap smear and cervical cultures. 12. Foley placement, catheterized urine sample. 13. Obtain an EKG (12-Lead). 14. Interpret Central Venous Pressure readings. 15. Perform intramuscular injections. 16. Perform pleural and peritoneal aspirations. Skills for Emergency Situations General The student will: (1) demonstrate an ability to recognize a situation requiring rapid intervention, (2) take the appropriate steps to provide emergency care, and (3) explain the pathophysiological and other reasons for particular management approaches, and (4) explain methods of monitoring effectiveness of therapy and avoidance of complications. Specific areas that the student should be prepared to address are patients presenting with the following: 1. Altered mental status. 2. Neurologic emergencies, including coma, meningitis, status epilepticus, CNS trauma, increased intracranial pressure, acute visual failure, neurogenic respiratory failure, and spinal cord compression. 3. Potentially life threatening complaints, including acute abdominal pain, chest pain, acute respiratory distress, alterations in consciousness, patterns of weakness and numbness, disturbances of visual perception, and disturbances of ocular mobility. 4. Cardiopulmonary collapse, including arrest in the newborn and including basic CPR for all ages. 5. Hemorrhagic shock, either obstetrical or surgical. 6. Septic shock. 7. Toxic ingestion (type, route, amount, and timing), including knowledge of the poison control center and other information resources in the management of the patient with an ingestion. 8. Childhood emergency, including acute clinical presentation and initial diagnostic assessment: shock, ataxia, seizures, delirium/coma, airway obstruction/respiratory distress, and apnea. 9. Psychiatric emergency, including initial management. 10. Initial basic resuscitation for burn victims and knowledge of the criteria for referral to a burn center. 11. Trauma: basic fundamentals of initial evaluation and management. Violence/Trauma The student will demonstrate an understanding of the epidemiology of and chronic debilitation caused by violence and trauma in the context of society and the family and, in so doing, will be able to do the following: 1. Recognize, evaluate, and treat appropriately trauma patients, including cranial, spinal, motor vehicular, penetrating wounds. 2. Recognize patterns and common presentation of domestic violence (particularly against women), understand immediate and long-term consequences of assault, and identify local resources for referral, legal advice, women's legal rights (state policy). 3. Provide anticipatory guidance about accidental injury prevention to the family of an infant, a toddler, a preschooler, school age child, and adolescent and direct injury prevention strategies to older children/adolescents. 4. Recognize patterns of and know how to elicit information on which to diagnose non-accidental injuries and abuse in children and know the ethical and governmental responsibilities of physicians in identifying and reporting suspected child abuse. 5. Recognize patterns and evidence of elder abuse and neglect. Critical/Perioperative Care The student will demonstrate a basic understanding of issues relating to the care of critically ill patients and patients before and after surgical procedures, with emphasis on assessing the acuity, and, where possible, the prognosis of the clinical problem as it relates to need for immediate management and the requirement for expert assistance. In so doing, the student will demonstrate skill in the care of patients presenting with/for the following: 1. Congestive heart failure. 2. Myocardial infarction. 3. Stroke and transient ischemic attacks. 4. Serious complications of labor and delivery, including pre-eclampsia, preterm labor, premature rupture of membranes, hemorrhage, abruption, fetal distress, dysfunctional labor, and shoulder dystocia. 5. Shock, including hemorrhagic, septic, cardiogenic and neurogenic. 6. Ataxia, seizures, delirium, and coma. 7. Airway obstruction, respiratory distress, and apnea. 8. Pulsatile abdominal mass. 9. Pre-surgical work-up, including the following: A. Evaluation of surgical risks factors and indications for surgery, including coronary artery disease, malignancies, joint complaints. B. Principles of informed consent and documentation. C. Anesthesia choice and management of potential serious complications with attention to the unique situations of pediatric, obstetric, and geriatric anesthesia. 10. Post-operative care, including principles of fluid management, nutrition considerations, management of drains, wound healing (steps, time course, and care), charting, patient education, and including the following: A. Risk factors for and management of post-operative infection. B. Indications for instituting mechanical ventilation. C. Pain management. D. Indications for and principles of blood product transfusion, including fresh frozen plasma. Fluid Management/Blood Products In a variety of medical situations, the student will demonstrate a basic understanding of fluid management by doing the following: 1. Obtaining historical information and physical exam findings to assess state of hydration. 2. Explaining the clinical consequences of electrolyte disturbances, including hypernatremia, hyponatremia, hyperkalemia, and hypokalemia, and discussing the effect of pH on the serum potassium. 3. Using knowledge of the electrolytic composition of various visceral fluids to calculate and write IV orders for initial fluid replacement and maintenance, with particular attention to patients with dehydration from gastroenteritis and diabetic ketoacidosis, septic shock, hypovolemic shock, and spinal shock. 4. Providing appropriate counseling regarding transfusion. 5. Knowing indications for transfusion of different blood components (red blood cells, platelets, fresh frozen plasma, coagulation factors). III. MEDICAL CONTENT KNOWLEDGE Ambulatory Problems The student will demonstrate an understanding of common acute and chronic illnesses and the impact of chronic illness on the patient, family, and society, which will include recognizing the importance and complexity of longitudinal, comprehensive, and integrated care of patients with chronic problems which involves multiple medications and simultaneous management of chronic and acute illnesses. The student will: 1. Describe the skills and information required to develop, in conjunction with the patient and patient's family, a chronic disease management plan that maximizes functional outcome and quality of life. 2. Understand the impact of chronic illnesses on school attendance and cognitive function and development in school-age children. 3. The student will describe the etiology, epidemiologic features, common signs and symptoms, differential diagnosis, and for psychiatric disorders the DSM-IV nomenclature, and will demonstrate how to use a focused, problem-oriented assessment to diagnose and initially manage (including when and how to make referrals) the following common acute and chronic illnesses/complaints/ findings: Cardiovascular problems: hypertension, dyslipidemia, congenital heart disease, coronary artery disease, heart murmur, symptoms of claudication, chest pain. Pulmonary problems: COPD, asthma, cough, shortness of breath. Endocrine problems: Diabetes mellitus, thyroid disease. Autoimmune disorders: SLE and rheumatoid arthritis Neurological problems: epilepsy and seizure disorder, multiple sclerosis, myasthenia gravis and polymyositis, narcolepsy and other sleep disorders, pain syndromes (e.g., neck and low back pain, especially those from herniated cervical or lumbar discs, carpal tunnel syndrome, Trigeminal neuralgia, and other sites of chronic pain), neurologic complications of systemic illness, headaches (especially migraines), dizziness and vertigo, dementia, Parkinson's disease, peripheral polyneuropathy. Female reproductive problems: Pre-conception counseling for women with chronic common medical conditions (e.g., HTN, DM, asthma) affecting the prenatal course and delivery, common causes of acute and chronic pelvic pain (endometriosis, pelvic infections, ovarian neoplasm); common breast complaints (mass, pain, and nipple discharge); common causes of abnormal vaginal bleeding patterns (complications of pregnancy, systemic illness, medication, disorders of genital tract); primary and secondary amenorrhea; vaginitis. Psychiatric problems: schizophrenia, mood disorders, anxiety disorders, personality disorders, substance abuse disorders, psychophysiologic disorders, eating disorders, somatoform and factitious disorders, and behavioral/school problems in children. Musculoskeletal problems: degenerative joint disease, gout, back pain, joint pain, limb pain. Renal/urologic problems: dysuria, normal bladder function (physiology and risk factors), hematuria, testicular mass, groin mass, incontinence, proteinuria. Gastrointestinal problems: dysphagia, gastroesophageal reflux, gallstones, hepatitis, appendicitis, peptic ulcer disease, irritable bowel syndromes, hepatomegaly, splenomegaly, abdominal mass, symptomatic internal or external hemorrhoids, diverticulosis, jaundice. Nutritional problems: Obesity, eating disorders, special nutritional concerns for children, geriatric population, and individuals with chronic disease. Hematalogic/neoplastic problems: anemia , heme positive stools, lymphadenopathy, pallor, bruising, weight loss. General/other: fever, sore throat, ear pain, URI, abdominal pain, vomiting, diarrhea, rash/dermatitis, trauma, impaired vision, impaired hearing. Inpatient Problems The student will demonstrate an understanding of the principles of hospital admission and skill in the inpatient admission work-up and subsequent management of the following problems: Cardiovascular problems: Thromboembolic disease; Myocardial infarction; Congestive heart failure; Dysrhythmias Pulmonary problems: Pneumonia; Chronic obstructive pulmonary disease Endocrine problems: Diabetic coma/Diabetic ketoacidosis Neurological problems: Stroke/Transient Ischemic Attack; Brain death and vegetative states; Seizures, Guillian Barre Syndrome, subarachnoid hemorrhage, altered mental status, spinal cord compression; meningitis Female reproductive problems: Labor, delivery, and postpartum Psychiatric problems: Acute psychotic break; suicidal patients Renal/Urologic problems: pyelonephritis, renal stones; renal failure Gastrointestinal problems: Pancreatitis; Upper and lower GI hemorrhages; Symptoms consistent with small bowel obstruction General/Other: Acute febrile illnesses: sepsis, cellulitis. Special Problems of Newborns: Jitteriness, jaundice, lethargy or poor feeding, respiratory distress, cyanosis, bilious and non bilious vomiting, hypoglycemia, and sepsis. Special Content Areas Infectious Conditions The student will demonstrate an understanding of the basic principles of infectious disease diagnosis and management, including attention to universal precautions and particular application to the following diseases/conditions: HIV infection; Meningitis and encephalitis; Sexually transmitted diseases; Postoperative/post- delivery infections; Infectious agents as they pertain to pregnancy (HIV, rubella, CMV, group B strep, herpes); Pneumonia/ Bronchitis; Urinary tract infection, Pyelonephritis. Neoplastic Conditions The student will demonstrate an understanding of the epidemiology (including risk factors, prevalence by age, gender, race) screening, presenting symptoms, diagnostic and management approaches for common neoplastic conditions and potentially neoplastic presentations 1. Common neoplastic conditions: Common cancers (breast, prostate, colon, lung, gynecologic melanoma and other skin cancers); Brain tumors; Benign neoplasms of the breast, ovary, uterus, cervix, and vulva; testicular masses; Spinal cord tumors; Cancer-related pain. 2. Potentially neoplastic presentations: Hypercalcemia (incidentally discovered); Thyroid nodules; Pancytopenia; pancreatic masses. Alcohol, Tobacco, Substance Abuse The student will demonstrate an understanding of the physiological effects on patients and the daily living effects on patients and their families of alcohol, tobacco, and drugs of abuse and initial skill in counseling patients and their families concerning the following external substances: 1. Physiological effects of: Alcohol, Nicotine, Cocaine, Narcotics, and other drugs of abuse. 2. Daily living effects of alcohol, tobacco, and illegal and illicit drugs on the following: A. Patient (economic, employment instability, reckless endangerment, etc.) B. Patient's family (economic, family systems, loss of safety, passive smoke, smoking or alcohol during pregnancy, etc.) 3. Counseling regarding the following: A. Signs and serious effects of harmful personal behaviors and habits (particularly, the risky behaviors of smoking and "binge" drinking in adolescents). B. Cessation of tobacco smoking and alcohol consumption and medical, pharmacologic, and community aids to assist in patient efforts to quit. Nutrition: General and in Special Circumstances The student will demonstrate (1) an understanding of nutritional principles and needs of patients of different ages and medical conditions, (2) skill in obtaining a routine diet history, and (3) skill in addressing and educating patients and their families about nutritional needs in the following medical situations/conditions: 1. Post-operative care; Pregnancy and postpartum, especially breastfeeding; Post-injury (metabolic response and nutritional needs); Indications for parental nutrition/total enteral nutrition (advantages, disadvantages); Medical disorders including chronic bowel diseases, morbid obesity, dyslipidemia, diabetes, renal or liver failure; Geriatric nutritional issues. 2. Special needs of children: Breastfeeding, formula feeding (including caloric adequacy), cow's milk, solid additives; Prevention and treatment of common pediatric mineral (iron, fluoride, calcium) and vitamin deficiencies; Nutritional assessment beyond infancy (including daily diet diary). Genetics The student will demonstrate an understanding of the role of genetics in many disorders by doing the following: 1. Determining which data from history and physical exam and which laboratory tests are appropriate when evaluating a child with a possible common genetic disorder or a congenital malformation. 2. Identifying those diseases/conditions that are determined or heavily influenced by genetics. 3. Identifying those diseases/conditions for which screening as disease risk assessment is appropriate. 4. Identifying those diseases/conditions that have genetic implications for offspring. Special Populations Age-Related Issues The student will demonstrate an understanding of the role of age in recognizing, diagnosing and appropriately managing patients with varied abnormalities and diseases, including the following specific issues for the various age groups: Infants/Children 1. Developmental evaluation of patients from infants to adolescents, recognizing growth and maturational milestones. 2. Initial evaluation of a child with "failure to thrive". 3. Communication with peripubertal adolescents and their parents the most important adolescent developmental changes and, performance of the sexual maturity rating (Tanner). 4. Evaluation of a child with delayed pubertal development. Adolescent/Adult 1. Normal life cycle physiology and how it impacts on the pathology with particular emphasis on menstrual cycle, puberty, and menopause. 2. Physiological, emotional, and societal influences of sexuality throughout life stages and their relationship to illness and health in traditional and alternative expressions of sexuality. Elderly 1. Cardiovascular problems of the elderly, including temporal arteritis, stroke. 2. Dementia, pseudodementia, and depression, with an understanding of how they influence other medical conditions, treatments, and living arrangements. 3. Diseases that impair movement, including arthritis, Parkinson's disease, and their influence on patients' disease and coping mechanisms. 4. Polypharmacy and dose-related issues in medical management of geriatric populations. 5. Appropriate role of extended care facilities and hospice. Gender, Ethnic, Cultural Issues In providing patient-centered care, the student will demonstrate an understanding of and sensitivity to gender, ethnic, and cultural issues at work in the physician-patient encounter and in the patient's response to disease, treatment, and wellness, with attention also to the following: 1. Respect for the individuality, values, goals, concerns, and rights of the patient and patient's family regarding a wide range of issues, including the following: A. Sanctity of life (brain death and vegetative states). B. Reproductive choice and infertility, safe sex counseling, contraception. C. Sexual orientation. D. Religion, folk remedies, income, education, and divorce. 2. Demonstration of gender, ethnic, and cultural sensitivity through gender-specific, ethnospecific, and culture specific activities and patient encounters. 3. Anticipation of female reproductive life cycle changes (puberty, first pregnancy, menopause) including physiologic factors and provide education to the patient to help maximize the acceptance of and adaptation to these normal life stages. 4. Differences between men and women in their disease presentations, risks, and responses to therapies. IV. FAMILY AND SOCIETAL INFLUENCES Psychosocial and Community Issues The student will demonstrate an understanding of the psychosocial, economic, behavioral, and community factors which influence a patient in his or her compliance and/or response to disease and wellness. The student will use that understanding to collect and incorporate appropriate psychosocial, cultural, family, and community data into an appropriate patient care plan by addressing the following specific issues: 1. Forces that can affect the process, timing, and reasons for the patient to seek medical care. 2. Effect of family relationships (both normal and abnormal) on health and illness. 3. Complex behavioral change and other factors involved in patient compliance with medical plan. 4. Age-appropriate "normative" behavior and serious psychiatric illness. 5. General medical illness in psychiatric patients and the extent to which medical/surgical illness may contribute to the psychiatric problem. 6. Role of education, economic development, occupational environment, social institutions, and recreation as important factors in the health status of communities (particularly, rural communities) and the importance of addressing the problems of individual patients and families by addressing community problems. 7. Community resources and programs (Public Health Department, Home Health Agency, Area Agency on Aging, Department of Human Resources, etc.) that contribute to a community's health care, unmet community health care needs and services and a plan for the community to address those unmet needs, and the role of the primary care physician as a leader and/or team player in addressing community needs. Economics, Cost Containment, Health Care System The student will demonstrate an understanding of basic principles of economics and health care systems and an appreciation of costs by doing the following: 1. Identifying and explaining professional and ethical issues posed by costs and reimbursement on primary care physicians, particularly under managed care systems. 2. Identifying and explaining the role of the primary care physician as a coordinator of care, including understanding the value of serving as a member of a health care team. 3. Identifying and explaining the role of the primary care physician in understanding the availability, the roles and effective use of both medical and non-medical consultation and referral resources. 4. Identifying and explaining the role of risk assessment, benefits calculation, and cost-of- treatment analyses in cost-effective health care, quality assurance, and risk-management decisions and using this information to formulate a rational plan of investigation and management of patients with a variety of diseases/conditions. 5. Identifying and explaining the impact of various barriers to access to health care, including barriers imposed by lack of insurance, third-party reimbursement systems, lack of availability of high-level technology, under-compensated and uncompensated care and rationing of services. 6. Identifying how health care reform may affect the definition and role of the primary care provider. 7. Identify differences in the various health care provider systems (e.g., PPO, HMO, fee-for- service; capitated systems) and how they affect the physician and patient.