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PGY1 Ambulatory Medicine

Location: Community Memorial Hospital Affiliated Clinics

Educational Goals & Objectives:

The Ambulatory Medicine rotation will provide the resident with an opportunity to become skilled in the prevention, evaluation and management of acute and chronic medical conditions commonly seen in the outpatient setting. Residents will rotate through the Ambulatory Clinic, for one month during their PGY1 year. Residents will gain exposure to a broad spectrum of medical conditions, ranging from core internal medicine issues to conditions requiring knowledge of allergy and immunology, nutrition, obstetrics and gynecology, ophthalmology, orthopedics, otolaryngology, preventative medicine, and psychiatry as they pertain to the general care of outpatients in the community. This exposure will complement experiences on other rotations. They will also learn about billing and coding, insurance coverage, Patient Centered Medical Home, and other concepts pertinent to systems-based practice in the outpatient setting.

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 care for their clinic patients.

II. All residents will demonstrate the ability to take a complete medical history and incorporate information from the electronic medical record.

• PGY1s should be able to differentiate between stable and unstable symptoms and elicit risk factors for the development of chronic disease.

III. Residents should be able to perform a physical exam appropriately focused on the patient’s presenting complaint.

IV. Residents will understand the indications, contraindications, complications, limitations, and interpretation of the following procedures and, as the rotation experience permits, become competent in their safe and effective use.

• PGY1s: biopsy of dermal lesions, cerumen removal, cryosurgery of skin, curettage of skin lesion, EKG interpretation, excision of subcutaneous lesions, incision and drainage of skin abscesses, minor laceration repair, office microscopy, pelvic examination and PAP smear, spirometry, splinting, suture removal, wet mount exam.

Medical Knowledge

I. Given the broad nature of Ambulatory Medicine, this curriculum is not intended to be an ever-growing list. Rather, it is designed to highlight skills critical to the core of the practice of outpatient medicine. Appropriate sections of subspecialty curricula will supplement the learning goals and objectives listed in this ambulatory curriculum.

II. PGY1s will become skilled in the timely triage of and approach to acute changes in health status, including:

  • Abdominal pain
  • Cough
  • Chest pain
  • Diarrhea
  • Electrolyte abnormalities
  • Elevated blood pressure
  • Fever
  • Headache
  • Heart murmur in adults
  • Hematuria
  • Lymphadenopathy
  • Insomnia
  • Obesity
  • Oliguria
  • Palpitations
  • Rash
  • Rhinorrhea
  • Shortness of breath
  • Sore throat
  • Vomiting

III. By the end of their PGY1 year, residents will also develop an understanding of the pathophysiology, clinical presentation, natural history, and therapy for common diagnoses, including:

  • Allergic rhinitis
  • Anemia
  • Asthma
  • Atrial fibrillation
  • Benign prostatic hypertrophy
  • Bronchitis and/or pneumonia
  • Celiac disease
  • Cellulitis
  • Chronic kidney disease
  • Chronic liver disease
  • Chronic pain
  • Conjunctivitis
  • Coronary artery disease
  • COPD
  • Congestive heart failure
  • Croup
  • Dermatitis
  • Diabetes mellitus
  • GERD and dyspepsia
  • Headache
  • Hyperlipidemia
  • Hypertension
  • Hypothyroidism
  • Low back pain
  • Obesity
  • Osteoarthritis
  • Osteoporosis
  • Sinusitis
  • Urinary tract infection

IV. Residents will understand the effective use and interpretation of commonly used tools in ambulatory care, including;

  • AMA Guidelines for Adolescent Preventative Services (GAPS)
  • APGAR score
  • Breast Cancer Risk Assessment Tool (National Cancer Institute)
  • Brief Patient Health Questionnaire (PHQ-9) and Depression Inventory
  • CAGE questionnaire
  • Cockcroft Gault and MDRD calculators
  • CRAFFT behavioral health screening tool
  • Developmental screening tests
  • Framingham Coronary Heart Disease Risk Score
  • FRAX (WHO Fracture Risk Assessment Tool)
  • HEADSSS questionnaire (Home, Education, Activities, Drugs, Sex, Suicide/Depression, Safety)
  • MELD score
  • Mini Mental State Examination
  • Montreal Cognitive Assessment

V. Residents will become familiar with frequently used complementary and alternative medicine treatments for common outpatient problems.

VI. Residents will become knowledgeable about evidence-based national screening and care guidelines and become comfortable counselling their patients on a broad spectrum of issues, including those revolving around growth and development, parenting, disease prevention and wellness promotion, and elder safety:

  • Age appropriate cancer screening
  • Advance directives
  • Contraception and safe sex
  • Domestic violence
  • Driving safety
  • Exercise and prevention of cardiovascular disease
  • Injury prevention
  • Nutrition and weight loss
  • Oral care
  • Smoking cessation
  • Substance abuse
  • Vaccination

VII. Residents will understand indications for ordering and interpretation of results from laboratory and imaging studies relevant to the diagnosis and treatment above conditions.

VIII. Residents will be fully trained in treatment and infection control protocols and procedures (e.g. personal protective equipment [PPE]) and trained clinically to properly recognize and care for COVID-19 patients.

Systems-Based Practice

I. PGY1s must have a basic understanding that their diagnostic and treatment decisions involve cost and risk and affect quality of care.

II. Residents must be aware of current quality issues in ambulatory care, such as cancer screening.

III. Residents will become familiar with the concept of the Patient-Centered Medical Home as well as other issues pertinent to the practice of outpatient medicine, such as coding and reimbursement, liability, and the costs and legal issues involved in running a practice.

Practice-Based Learning and Improvement

I. All residents should be able to access current clinical practice guidelines from USPTF, ADA, JNC, NCEP and other sources to apply evidence-based strategies to patient care.

II. Residents will learn to use the electronic medical record effectively and understand the definition of meaningful use.

III. All residents should learn to function as part of a team, including the primary care physician, nurse, midlevel provider, medical assistant, and social worker to optimize patient care within the context of a Patient-Centered Medical Home.

IV. All residents should respond with positive changes to feedback from members of the health care team.

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. All 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.

Interpersonal and Communication Skills

I. PGY1s must demonstrate organized and articulate electronic and verbal communication skills that build rapport with patients and families, convey information to other health care professionals, and provide timely documentation in the chart.

II. By the end of the PGY1 year, residents must also develop interpersonal skills that facilitate collaboration with patients, educate patients, and where appropriate, promote behavioral change.

Teaching Methods

I. Supervised patient care in the clinic

  • 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 more independently with patients and present cases to faculty.
    • For PGY1s, the initial emphasis will be on diagnosis and basic management.

II. Conferences

  • Scheduled didactics
  • Grand Rounds
  • Journal club

III. Independent study

Evaluation

I. Case and procedure logs

II. Mini-CEX bedside evaluation tool

III. NEJM Question Bank

IV. Verbal mid-rotation individual feedback

V. 360 Evaluation – twice per year

VI. New Innovations Internal Medicine (for Psychiatry Residents) Evaluations

Rotation Structure

I. Residents will be assigned to a preceptor and location at the beginning of their rotation.

II. Residents should notify the attending physician as well as the Program Director promptly if on any occasion they cannot be in clinic at their assigned time.

III. Residents will review TIPS (clinical pearls) each week in clinic with their preceptor. Residents may also be asked to do focused literature searches or presentations by their preceptor.

IV. Call and weekend responsibilities to be determined by the attending physician.

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

V. Residents have scheduled didactic conferences and should be excused in a timely fashion to attend.