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Urgent Care

Urgent Care Educational Goals & Objectives

Urgent Care is a required rotation for PGY3s. The Urgent Care rotation will provide the resident with an opportunity to evaluate and manage patients with common urgent conditions or as follow-up after Urgent Care, Emergency Department visits, or inpatient care. Training will emphasize the rapid gathering of a pertinent history, a focused physical exam, and timely decision-making. Residents will learn to identify patients that need a higher level of care and to manage multiple patients simultaneously. Residents will follow patients from initial encounter through appropriate social and medical disposition. Finally, residents will become skilled in the performance of procedures necessary to manage conditions commonly seen in Urgent Care.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. All residents must be able to provide compassionate, culturally-sensitive, and appropriate care for patients presenting to Urgent Care.

  • Residents should seek directed and appropriate specialty consultation when necessary to further patient care.
  • Residents should ensure an appropriate follow up plan is in place at discharge.

II. Residents will demonstrate the ability to take a succinct, pertinent history from patients, family, or caretakers and perform a focused physical exam. Residents should also be able to identify unstable patients or patients who require a higher level of care.

III. Residents will understand the indications, limitations, and complications of the following procedures, with the goal of becoming competent in the their safe and effective use:

  • Blood draw, arterial and venous
  • Casting and splinting
  • Excisional and punch biopsy and lesion removal
  • Fluorescent staining of cornea and slit lamp exam
  • Foreign body removal
  • I&D and wound debridement
  • Joint injection/aspiration
  • Local and topical anesthesia and digital nerve block
  • Nail removal
  • Nasal packing
  • Reduction of joint dislocations
  • Suturing and gluing of lacerations
  • Wart destruction

Medical Knowledge

I. Residents will become comfortable with a basic approach to an array of conditions affecting patients from pediatrics to geriatrics. The goal is to understand basic pathophysiology, differential diagnosis, focused diagnostic evaluation, and initial therapy for these disorders. As experience depends on the case mix at any given time, residents are strongly encouraged to develop their knowledge further with supplemental reading to ensure they become familiar with an approach to both common presenting symptoms and signs, such as:

  • abdominal pain
  • back pain
  • breast mass
  • chest pain
  • cough or shortness of breath
  • diarrhea or constipation
  • dizziness or vertigo
  • dysuria
  • failure to thrive
  • falls
  • fever
  • headache or facial pain
  • hoarseness
  • incontinence
  • nausea or vomiting
  • pain
  • rash
  • vision or hearing loss
  • vaginal bleeding
  • weakness

as well as the following common conditions:

  • abnormal liver function tests
  • acute kidney injury
  • allergic reaction to medication
  • anemia
  • anticoagulation and coagulopathies
  • anxiety, panic attacks, and depression
  • ascites
  • atrial fibrillation
  • Bell’s palsy
  • benign positional vertigo
  • bites and stings
  • child, elder, and partner abuse
  • common eye, ear and mouth disorders
  • COPD exacerbation
  • deep venous thrombosis
  • dehydration
  • delirium
  • dementia
  • diabetes, poorly-controlled
  • drug seeking behavior
  • electrolyte abnormalities
  • hypertension, poorly-controlled
  • gout
  • nephrolithiasis
  • pregnancy
  • sexually transmitted diseases
  • skin infections: abscess, cellulitis, ulcer, wound
  • sprains, fractures, and overuse injuries
  • syncope
  • upper respiratory tract infections: otitis, pharyngitis, rhinitis, sinusitis
  • lower respiratory tract infections: bronchitis, community-acquired pneumonia
  • urinary tract infections
  • urticaria

II. Residents will show progression in knowledge of acuity, analytical thinking, appropriate diagnostic evaluation, and initiation of guideline-based management for both adult and pediatric conditions.

III. Residents will be able to independently assess patients and triage patient management tasks appropriately to effectively manage multiple patients with acute complaints in a timely fashion.

IV. Residents will be able to understand the indications for ordering and interpretation of results from diagnostic studies, including:

  • Arterial blood gas – interpretation of oxygenation and basic acid-base status
  • Computed tomography imaging of head, chest and abdomen
  • EKG
  • CBCD and chemistries
  • Radiographs of chest, abdomen, and extremities
  • Ultrasound of abdomen or pelvis

Residents must follow up on all diagnostic studies ordered during an Urgent Care session or transition responsibility to another provider.

Practice-Based Learning and Improvement

I. Residents should be able to access current clinical practice guidelines and other references to find evidence-based answers to targeted clinical questions.

II. Residents should learn to coordinate care by communicating with the patient’s primary care doctor or other consultants involved in the patient’s care.

III. Residents should learn to assess their practice patterns as well as respond with positive changes to peer review and feedback from members of the health care team.

Interpersonal and Communication Skills

I. Residents must document in the EMR medical findings, decision-making, and patient communications in a timely and articulate fashion that effectively communicates information to other providers.

II. Resident should be able to counsel patients about the risks and benefits of testing and treatments that may be performed in Urgent Care.

III. Residents must demonstrate interpersonal skills that facilitate the exchange of information and collaboration with patients, their families, and other health professionals.

IV. Residents should gain experience in managing social dynamics, including dealing with difficult patients.

V. Residents need to ensure patients and their families understand discharge and follow up instructions.

Professionalism

I. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.

II. Residents should be able to educate patients and their families in a manner respectful of gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation on choices regarding their care.

III. Residents should be able to use time efficiently to see patients and chart information

Systems-Based Practice

I. Residents should recognize situations that require notification of Public Health, DMV, Child Protective Services, or other agencies.

II. Residents should be aware of cost-conscious care measures in the Urgent Care setting.

III. Residents should look for opportunities to introduce quality improvement into the protocols in Urgent Care.

IV. Residents should recognize how to transition patients to a higher level of care.

Teaching

I. Residents will care for patients under attending supervision in Urgent Care.

II. Residents will initially be directly observed with patients to facilitate the acquisition of excellent history taking, physical exam, and procedural skills.

  • As residents become more proficient, they will interact independently with patients and present cases to faculty.
  • Initial emphasis will be on diagnosis and basic management.
  • When residents have mastered these skills, focus will be on medical decision making, and residents will work with supervising physicians to finalize a care plan.

III. Conferences

  • Specialty-specific didactics

IV. Independent study

Evaluation

I. Case and procedure logs

II. Mini-CEX

III. Verbal mid-rotation individual feedback

IV. Attending written evaluation of resident at the end of the month based on observations and chart review

Rotation Structure

I. Residents should contact the Urgent Care Medical Director 1-3 days prior to the rotation start date to determine start time and location.

II. Residents will spend scheduled time in Urgent Care with the goal of providing a broad range of experience to achieve the above educational goals.

  • Residents are the primary care providers for their Urgent Care patients. Residents will be involved in discussion of patient presentation, generation of a differential diagnosis, development of a treatment plan, and patient follow up. In addition, residents will be involved in bedside procedures as is appropriate.

III. Case-based learning is most effective. Nightly reading/study should be based on patients seen during the day.

IV. Residents may be asked to do focused literature searches or presentations during the course of the rotation.

V. Call and weekend responsibilities TBD by the attending physician.

  • Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.

VI. Residents have specialty-specific didactics and should be excused in a timely fashion to attend.

VII. Residents wishing to elect this rotation prior to their senior year may submit a request to their program director. Decisions will be made on a case-by-case basis. For more junior residents participating, the attending physician will tailor the learning objectives and expectations to be commensurate with the resident’s progress in training.