Ambulatory Medicine

AMBULATORY MEDICINE COMPETENCY-BASED CURRICULUM

EDUCATIONAL RATIONALE

The ambulatory Medicine rotation focuses on the delivery of developing skills needs to provide optimal primary health care. Patients often present to general internists with clinical problems related to other subspecialty domains. Thus medicine residents need exposure to a wide variety of experiences that help them develop a broad knowledge base in the approach to common complaints encountered in an outpatient primary care office.

GOALS

The aim of this rotation is to expose residents to the common patient conditions encountered in ambulatory medicine and to gain expertise in them. To achieve this goal the resident will spend time in the Internal Medicine Faculty Practice (IMFP) and in a variety of ambulatory sites available.

Residents will start by developing the appropriate interpersonal skills to establish a quality doctor-patient relationship with sensitivity to patient's emotional, physical, cultural and socioeconomic environment. Thus, the resident is able to abstract the necessary history, identify the barriers that stand in the way of patient compliance and at the same time serve as an educator. Next, the resident physician will develop a broadbased knowledge of common ambulatory problems and chronic medical conditions to be able to diagnose and treat these problems. The resident will keep current in and incorporate evidence-based medicine in the risk-assessment, treatment and long term management of the patient. This requires skillful management of chronic illness, as well as prevention of disability and disease through screening, education and promotion of behavioral change and preventive treatment. The resident will implement the coordination of care with other disciplines, with consideration of the economic aspects of the managed care health insurance system. There will be a focus on the concept of continuity of care and resident physician accessibility. This is done with the long term goal of progressive patient responsibility and increasing the size of each resident's primary care patient panel over time.

EDUCATIONAL EXPERIENCE

During the ambulatory medicine rotation residents will spend time in various outpatient settings including offices, Ambulatory Care Center, and other clinics. The schedule can be personalized to suit the specific interests of the resident. Experiences offered include, but are not limited to office gynecology, dermatology, otolaryngology, office orthopedics/sports medicine, and geriatrics.

Residents can also spend time in private practice primary care internal medicine and family medicine offices.

Residents will be able to apply and master their acquired skills in their continuity experience at the IMFP. The ambulatory month rotations will help residents better care for their continuity patients by broadening their clinical skills and by helping them learn the reasons for and expectations from subspecialty consultations.

  1. Ambulatory Experience (AM)
    1. Outpatient activities for residents are conducted as arranged by their supervising attending
    2. Residents are expected to attend all sessions, outpatient activities, and practices as scheduled
    3. Patients are assigned in clinics and offices by the attending physicians.
      Every effort is made to select patients of "interest".
    4. Depending on numbers of individuals on the rotations and clinic/office loads attempts are made to permit residents to spend the first few experiences seeing patients together with attending physicians, so as to better introduce them to the patient evaluation.
  2. Didactic Conferences (DC)
    Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties.
  3. Continuity Clinic (CC)
    Twice weekly thorough out residency resident will be able to apply their knowledge and clinical skill in the care of their continuity patients.

EVALUATIONS

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and socialbehavioral sciences, as well as the application of this knowledge to patient care.

Goals and Objectives-PGY1 Learning Activities* Assessment
Name 5 indications for each of these common vaccines: tetanus, pneumococcal,
influenza, MMR, hepatitis A, hepatitis B
AM, DC AE, DC, MKSAP
List ADA or AACE guidelines for screening, diagnosis, treatment, and health
maintenance for type 2 diabetes
AM, DC AE, DC, MKSAP
List JNC guidelines for screening, evaluation, and treatment of hypertension AM, DC AE, DC, MKSAP
Goals and Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
List NCEP cholesterol treatment guidelines AM, DC AE, DC, MKSAP
Describe the NAEP guidelines for the management of asthma AM, DC AE, DC, MKSAP
Name the AHCPR red flags for backache AM, DC AE, DC, MKSAP
Read a complete PFT and identify the diagnosis AM, DC AE, DC, MKSAP
Describe the USPSTF recommendations for age appropriate screening tests, counseling, and vaccination of health adults AM, DC AE, DC, MKSAP

2) Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health in the ambulatory setting.

Goals and Objectives-PGY1 Learning Activities* Assessment
Acquire accurate and relevant history from the patient in an efficiently customized, prioritized, and hypothesis driven fashion. AM, DC AE, DC, MKSAP
Perform an accurate physical examination that is appropriately targeted to the patient's complaints and medical conditions. Identify pertinent abnormalities using common maneuvers. AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Synthesize all available data, including interview, physical examination, and preliminary laboratory data, to define each patient's central clinical problem. AM, DC AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. AM, DC AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. AM, DC AE, DC, MKSAP
Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g., family, records, pharmacy). AM, DC AE, DC, MKSAP
Develop independent differential diagnoses, preliminary analysis and therapeutic plans for common ambulatory conditions AM, DC AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment
Perform semiannual chart review for the IMFP PI project. Compare results of chart review with national benchmarks and identify reasons for deficiencies. Develop an action plan for improvement with faculty supervision. AM, DC AE, DC, MKSAP
Demonstrate ability to identify strengths and weaknesses in knowledge base of common outpatient medical problems. AM, DC AE, DC, MKSAP
Effectively utilize medical databases to identify original research articles. AM, DC AE, DC, MKSAP
Identify basic types of studies and statistical analysis in the medical literature with assistance. AM, DC AE, DC, MKSAP
Attend, participate and contribute to journal clubs/evidence based medicine conferences on a regular basis. AM, DC AE, DC, MKSAP
Demonstrate ability to receive, respond appropriately to, and incorporate feedback into one's daily practice AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct focused clinical questions. AM, DC AE, DC, MKSAP
Effectively search evidence based summary medical information resources AM, DC AE, DC, MKSAP
Appraise clinical guidelines with assistance. AM, DC AE, DC, MKSAP
Independently appraise clinical guidelines, meta-analyses and original research articles. AM, DC AE, DC, MKSAP
Integrate clinical evidence, clinical context and patient preferences into decision making. AM, DC AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1 Learning Activities* Assessment
Apply empathy in all patient encounters AM, DC AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team AM, DC AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending AM, DC AE, DC, MKSAP
Compose clear and timely progress notes and preventive examinations AM, DC AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate AM, DC AE, DC, MKSAP
Teach colleagues effectively AM, DC AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties AM, DC AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all AM, DC AE, DC, MKSAP
Respect patients and their families, staff and colleagues AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings AM, DC AE, DC, MKSAP
Demonstrate integrity AM, DC AE, DC, MKSAP
Respond to phone calls and pages promptly AM, DC AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases AM, DC AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients. AM, DC AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of ambulatory patients AM, DC AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. AM, DC AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices AM, DC AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized AM, DC AE, DC, MKSAP

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY-2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

Educational Resources

  1. Supervising clinicians-didactic rounds and concurrent patient care
  2. Medical literature including assessment of knowledge using the MKSAP
  3. Medical Grand Rounds weekly.
  4. Scheduled didactic conferences including: medicine morning report, journal club, ambulatory care conference, EBM conference
  5. Saint Barnabas Medical Center library, librarians, and online references/resources.

REFERENCES

• The Rational Clinical Exam
http://jama.amaassn.org/cgi/collection/rational_clinical_exam

• ACP Journal Club Plus
http://www.acpjc.org/

• NCEP/ATP III guidelines
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

• Framingham 10 Year Cardiovascular Risk calculator
http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof

• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
http://www.nhlbi.nih.gov/guidelines/hypertension/

• Executive Summary: Standards of Medical Care in Diabetes—2010
http://care.diabetesjournals.org/content/33/Supplement_1/S4.full.pdf

• Depression Screening: PHQ2, PHQ9
http://www.cqaimh.org/pdf/tool_phq2.pdf
http://www.cqaimh.org/pdf/tool_phq9.pdf

• Breast Cancer Risk Assessment Tool (NCI)
http://www.cancer.gov/bcrisktool/

• WHO Fracture Risk Assessment Tool
http://www.sheffield.ac.uk/FRAX/

• NHLBI Guidelines for the Diagnosis and Management of Asthma
http://www.nhlbi.nih.gov/guidelines/asthma/

• ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
http://circ.ahajournals.org/cgi/content/full/116/17/e418

• CDC Immunization Recommendations, United States -
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

• CDC Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

• USPSTF Guide to Clinical Preventative Services
http://www.ahrq.gov

• USPSTF Colon Cancer Screening Recommendations
http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm

• USPSTF Breast Cancer Screening Recommendations
http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

• USPSTF Prostate Cancer Screening Recommendations
http://www.uspreventiveservicestaskforce.org/uspstf/uspsprca.htm

• KDOQI Clinical Practice Guidelines for Chronic Kidney Disease
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm

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