PA and 4th Year MD Student Evaluation Contributing Evaluation Form Instructions: -Please select one descriptive box for each of the 14 competencies listed below -Most students should be graded Acceptable (~70% of students) -Advanced should be chosen for role model students (special skills should be present to achieve this category) -Students with a critical deficiency or multiple deficiencies should be given opportunity to improve after mid-month feedback. Evaluator Name*BuSanda Frost, ARNPGrant Harrell, MDHarvey Rohlwing, MDHenry Storch, MDJerry Stein, MDMathew Neibaur, MDMichelle Nall, ARNPPetar Breitinger, PARalph Rice, PARosella Smith, MDShalon Buchs, PAotherOther Evaluator NameDate* Student Name* First Last Rotation*Mobile Outreach ClinicSite Day* Monday Tuesday Wednesday Thursday Friday Patient care*Critical Deficiencies -- Unable to collect accurate history or physical examDeficient -- Inconsistently able to acquire accurate historyAcceptable -- Consistently acquires accurate and relevant historiesProficient -- Acquires H&P in a prioritized, & hypothesis-driven fashionAdvanced -- Obtains historical subtleties, that improve the differential diagnosisNot Observeda. Medical Interview & Physical Exam: Student synthesizes essential, accurate information to define patient's clinical problem(s). [PC1, EPA 1,10]*Critical Deficiencies -- Care plans are often incomplete or inaccurateDeficient -- Inconsistently develops an appropriate care planAcceptable -- Consistently develops an appropriate care planProficient -- Appropriately modifies care plans based on clinical course and patient preferencesAdvanced -- Role models and comprehends complex, patient-centered careNot Observedb. Written Patient Record and Decision Making: Can synthesize a patient care plan and justify why urgent or emergent care is needed [EPA 7,10]*Critical Deficiencies -- Attempts to perform procedures without sufficient skill or supervisionDeficient -- Insufficient technical skill for safe completion of common proceduresAcceptable -- Possesses basic technical skill for the completion of common proceduresProficient -- Possesses good technical skill & has successfully performed procedures related to rotationAdvanced -- Maximizes comfort and safety when performing proceduresNot Observedc. Procedures: Possesses technical skill to successfully complete procedures relevant to the clinical rotation [PC, PBLI, EPA 11]Medical Knowledge*Critical Deficiencies -- Lacks scientific, socioeconomic or behavioral knowledge required to provide competent patient careDeficient -- Unable to demonstrate improved scientific, socioeconomic or behavioral understanding when faced with a similar scenario for a second timeAcceptable -- Possesses the scientific, socioeconomic and behavioral knowledge required to provide care for common medical conditionsProficient -- Possesses the scientific, socioeconomic and behavioral knowledge required to provide care for complex medical conditionsAdvanced -- Possesses scientific, socioeconomic and behavioral knowledge required to diagnose and treat uncommon, or complex conditionsNot Observeda. Clinical Knowledge: Integrates clinical sciences with clinical application [MK1,2, EPA 7]*Critical Deficiencies -- Misinterprets clinical and/or lab data, thereby causing misdiagnosisDeficient -- Often interprets normal findings as abnormal or vice-versaAcceptable -- Acceptable level of analyzing clinical and lab dataProficient -- Able to synthesize clinical data and correlate them correctly with minimal preceptor inputAdvanced -- Able to function autonomously distinguishing normal and abnormal findings and correlating this with clinical and lab dataNot Observedb. Problem Solving and Critical Thinking: Synthesizes and analyzes data correctly, correlates clinical and lab data, accurately determines active problems, distinguishes normal from abnormal findings [MK 8, EPAPA 3, 10]*Critical Deficiencies -- Forms differential diagnoses not justified by clinical data, or unable to form a differential diagnosisDeficient -- Typically able to only come up with a rudimentary differential diagnosisAcceptable -- Able to consistently form a small but correct differential diagnosis. (2-3 reasonable possibilities)Proficient -- Able to form a broad based and correctly prioritized differential diagnosisAdvanced -- Needs no direction making an accurate & prioritized DDx w/ supporting evidence from H&PNot Observedc. Differential Diagnosis: Formulates a differential diagnosis, prioritizes it based on knowledge gathered [MK 9, EPAPA 2]*Critical Deficiencies -- Lacks foundational knowledge to apply tests & procedures to patient careDeficient -- Inconsistently interprets basic diagnostic testsAcceptable -- Consistently interprets basic diagnostic tests accuratelyProficient -- Chooses testing wisely & accurately interprets complex diagnostic testsAdvanced -- Anticipates and accounts for pitfalls and biases when interpreting tests and proceduresNot Observedd. Knowledge of diagnostic testing and procedures [MK2, EPA 3]Interpersonal & Communication Skills*Critical Deficiencies -- Conveys inaccurate data that may pose detrimentalDeficient -- Provides some relevant patient data but organization & flow impairs effectivenessAcceptable -- Provides oral presentation with minimal prompting; typically accurate w/ history & examProficient -- Able to adapt style & length of presentation according to specialty & complexity of caseAdvanced -- Accurately & succinctly communicates in all clinical situations including admission, consultation & care hand-offsNot Observeda. Oral Case Presentation [IPC 2, 6, EPAPA 6,9]*Critical Deficiencies -- Does not engage in shared decision-making or take preferences into accountDeficient -- Respects patient preferences when offered, but does not actively solicit preferencesAcceptable -- Engages patients in shared decision making in uncomplicated conversationsProficient -- Incorporates patient preferences and shared decision making across a variety of patient care scenariosAdvanced -- Role models effective communication and fosters therapeutic relationships in both routine & challenging situationsNot Observedb. Communicates Effectively with Patients and Caregivers [EPA 9,11, IPCS 1,2,4]*Critical Deficiencies -- Communication strategies hamper teamworkDeficient -- Uses unidirectional communication that fails to utilize wisdom of the teamAcceptable -- Sometimes engages in collaborative communication with team membersProficient -- Consistently engages in collaborative communication with team membersAdvanced -- Role models/teaches collaborative communication to enhance patient care, even in challenging settingsNot Observedc. Communicates effectively in interprofessional teams (e.g. peers, consultants, nursing, and other professionals). [IPCS, EPAPA 8,9]Practice-Based Learning and System Based Practice*Critical Deficiencies -- Unwilling to self-reflect on practice or performanceDeficient -- Lacks tools or misses opportunities to self-reflect on practice or performanceAcceptable -- Inconsistently self-reflects on practice performance & inconsistently acts upon reflectionsProficient -- Regularly self-reflects on practice or performance & consistently acts upon those reflectionsAdvanced -- Regularly self-reflects and seeks external validation to maximize practice improvementNot Observeda. Monitors practice with a goal for improvement [EPAPA 12, PBLI 1]*Critical Deficiencies -- Never solicits feedbackDeficient -- Rarely seeks, or sometimes responds to feedback in a defensive fashionAcceptable -- Solicits feedback only from supervisors, usually incorporates feedbackProficient -- Solicits feedback from all members of the team and patientsAdvanced -- Performance continuously reflects incorporation of solicited and unsolicited feedbackNot Observedb. Learns and improves via feedback [PBL 3, EPAPA 9]Professionalism*Critical Deficiencies -- Lacks empathy or compassion for patients & caregiversDeficient -- Inconsistently demonstrates empathy, compassion & respect for patients & caregiversAcceptable -- Consistently respectful with patients, caregivers & members of team, even when challengingProficient -- Demonstrates empathy, compassion & respect to patients and caregivers in all situationsAdvanced -- Role models compassion, empathy & respcect for patients and caregiversNot Observeda. Has professional and respectful interactions with patients, caregivers and members of the inter-professional team [Prof, EPAPA 9]*Critical Deficiencies -- Sometimes dishonest in documentation, or scholarly activityDeficient -- Honest in clinical interactions, documentation, & scholarly activity.Acceptable -- Honest & forthright in clinical interactions, documentation, and scholarly activityProficient -- Demonstrates integrity, honesty, & accountability to patients, society & the professionAdvanced -- Assists others in adhering to ethical principles of integrity, honesty, & professional responsibilityNot Observedb. Exhibits integrity and ethical behavior in professional conduct [Prof, EPAPA 9]Summary Comments* Please include at least one area where student needs improvement, with specific examples. Also include observations about physical exam and histories.