INDIANA UNIVERSITY SCHOOL OF MEDICINE MEDICINE-PEDIATRICS RESIDENT CONTINUITY CLINIC CURRICULUM

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1 INDIANA UNIVERSITY SCHOOL OF MEDICINE MEDICINE-PEDIATRICS RESIDENT CONTINUITY CLINIC CURRICULUM Mary Ciccarelli, M.D., Medicine-Pediatrics Continuity Clinic Director Alex Djuricich, M.D. Medicine-Pediatrics Program Director I. OVERVIEW Since the primary goal of this curriculum is to teach pediatric residents an approach to primary care in the ambulatory setting, the teaching should be focused around the clinical care experience of the continuity clinic. It therefore, should center around each patient-resident interaction. A critical information base will provide the bases of the curriculum. By the end of the PL-4 year, all residents should be able to state the approach to the patient presenting with any of the topics on the attached ambulatory issue lists. During their residency, the residents should develop progressive skills in patient care and practice management. The four-year longitudinal aspect of this course allows each resident to self-direct his/her progression through the objectives. The importance of health supervision and normal child development should be emphasized early in the experience. With time, the resident will progress through the educational development of ambulatory clinical diagnostic and therapeutic skills. As the resident s abilities improve, there is a progression in resident independence and an expectation of skills proficiency. Upper level residents can become involved in teaching projects via mini-lecture presentation, staff in-service lectures, and the development of patient education handouts. Self-directed learning and long-term practice management skills should be interwoven throughout the longitudinal experience. II. OVERALL GOALS OF CONTINUITY CLINIC A. Preventive medicine 1. Residents will understand and apply preventive medicine and anticipatory guidance strategies in patient encounters. a. Implementation of prevention 1) Residents will promote prevention as a health care priority 2) Residents will select the appropriate preventive medicine procedures for individual patients 3) Residents will conduct and interpret clinic procedures related to prevention 4) Residents will effectively counsel patients regarding prevention and methods to modify risk factors for disease by counseling to achieve behavioral change.

2 Examples: Cholesterol testing, dietary counseling, exercise counseling, immunizations, injury prevention, sunblock use, tobacco/alcohol/drug counseling, pregnancy b. Prevention theory 1) Residents will develop a critical approach to reading the prevention literature. Examples: Risk factors, screening criteria, cost effectiveness, intervention c. Normal childhood 1) Residents will understand the development and behavior of normal children 2) Residents will teach basic child development and anticipatory guidance to parents during well-child visits Examples: Parenting skills feeding, discipline, education, recreation, normal childhood behavior at various ages d. Life cycle of adults 1) Residents will develop skills in the evaluation and management of the adult patient as relates to the life cycle and risk management. Examples: contraceptive prevention, functional assessment, menopause, advance care planning. B. Focused patient assessment 1. Residents will perform focused patient assessments in the ambulatory setting. 2. Residents will exhibit knowledge of the natural history of common disorders of children and adults and apply this in the clinical setting. 3. Residents will appropriately utilize common office procedures. C. Communication 1. Residents will demonstrate effective communications and counseling skills with their patients. Examples: Conflict between physician-patient values, patient autonomy, confidentiality, informed consent, truth telling, facing mistakes, management of AIDS, management of difficult patients (uncooperative, argumentative), child abuse/neglect, vulnerable child syndrome, dysfunctional parenting, adolescent-physician interactions, psychosocial evaluation, behavior counseling, patient and family reactions

3 to physical illness, dying and grief, compliance issues, management of potentially harmful health habits. 2. Residents will demonstrate development of a therapeutic physician-patient relationship and understand the benefits of this relationship. 3. Residents will use and provide consultations with medical colleagues to enhance patient care and secondarily, their own learning. Examples: Providing internal medicine or pediatric consultations, appropriate use of subspecialty consultants and procedural needs, care coordination 4. Residents will interact with clinic staff productively, in the roles of co-workers and teachers. Examples: Physician-nurse communication/documentation, staff health education 5. Residents will develop a role within the community as a representative of health promotion. Examples: School system responsibility, community support services, community health outreach, legal medicine D. Practice management skills 1. Residents will utilize the medical literature as a source of continued medical education. Examples: Residents should be expected to read about new diagnoses they encounter, they should be able to formulate a question and use the evidence to obtain up-to-date information. 2. Residents will participate within and work constructively to enhance their practice environment. Examples: Quality assurance, office management III. RECOMMENDED CLINIC STRUCTURE PGY1 residents should be expected to examine 3-4 return patients and 1-2 new patients at each clinic session. Upper level residents will be able to increase their own number of scheduled patients based on their ability to accommodate the increase and the particular patients needs. The residents patients should be maintained as a separate pool, identified by a charting or commuter mechanism which allows easy identification for schedulers. Well child care/routine care should be scheduled with the identified residents. Ill visits must be scheduled as needed in light of the resident s limited availability at the site. Office staff should be encouraged to communicate with the

4 resident regarding laboratory or consult results when non-emergent decisions can be made. Patient encounters should employ a focused assessment technique. Residents will maintain a record of the patients they see during each clinic session as well as procedures preformed. Staffing of all patients will be triggered by the resident s educational level and the patient type (New patient, Acute visit, Routine scheduled visit or Well child). The following are general guidelines for staffing by year of residency: PL-1 Every patient must be staffed with the preceptor for at least the first six months. The history and physical findings are reviewed and the resident suggests an impression and plan. Brief teaching about pertinent points frequently occurs during this portion of the session. The preceptor then sees the patient with the resident. The history may be summarized for the parent/patient to double-check accuracy and understanding. The preceptor must observe or repeat the key elements of the visit which he/she determines to be critical. PL-2 The faculty must always hear the resident presentation of the case and personally repeat or elaborate on the resident s history and physical by ascertaining the possible teaching points and/or severity and uncertainty of the case. Care should be taken to encourage the resident s longitudinal relationship with the patient. Faculty may introduce themselves as the physician s supervisor, a second more experienced physician who can give further advice. Each year sequentially, more independence is granted to each resident based on individual skill in both the decision-making and communication with patients. PL-3/4 The faculty will likely further decrease the expectations for detailed presentations (when appropriate) and encourage more independence in decision-making and communication with patients. All patients should be discussed at the point of care for billing purposes. Case Presentations and Teaching When staffing a case, discussion should include a synopsis of at least one dimension of the case, i.e., the severity or progression of chronic disease, the differential diagnosis of a new problem, the rationale for a diagnostic test selection or medication selection, the parenting issue identified, the preventive medicine strategies employed, or a difficulty in communication during the encounter. The length of time spent staffing each patient will vary by case. Preceptors are encouraged to directly observe part of a residentpatient encounter ideally at least once a week. These observations should also be recorded on the mini-cex forms. Residents are required to submit at least four mini-cex evaluations per year.

5 As follow-up, the residents should review and manage charts with telephone messages, lab or consultation results. The charts of patients who missed that day s appointment should be reviewed and prioritized by the resident to select those high risk patients who need specific follow-up. Upper level residents may participate in non-physician education sessions, depending on the continuity clinic site and the perceived needs of the location. These could take the form of staff in-service lectures (i.e., interpreting tympanometry) and/or community-service activities (i.e., community health-related issues), annually or more frequently as interest and concomitant block rotations allow. IV. INSTRUCTIONAL STRATEGIES A. Discussion Topics Ideally there should be a topic of discussion each week. These should be short (5-7 minute). The pediatric vignettes and the ambulatory medicine web-based curriculum are sources for discussion. Clinical toolboxes are available to use in the clinical practice for ADHD, obesity, childhood immunizations, asthma, CHF, diabetes, geriatric falls, Down syndrome, etc. These are available through the Dyson Community Pediatrics Initiative, the ISDH Chronic Disease Management Program and the IUSM Geriatric Education Network Initiative (GENI). B. Didactic Teaching Residents will receive a series of ambulatory care lectures scheduled during the traditional noon conference time during the four years of their residency in both the medicine and pediatric series. C. Reference Text Each continuity clinic site should have current editions pediatric textbooks available on-site for reference use. The AAP Guidelines for Health Supervision II or Bright Futures can be used by the resident to prepare for well-child encounters, since it provides a format for these visits both for interviewing and anticipatory guidance. Developmental screening tools such as the Denver or Ages & Stages scales can be used. Residents will be encouraged to use a routine format to systematize their agerelated encounters. The AAP Report of the Committee on Infectious Diseases (Red Book) provides a complete overview of information regarding immunizations, as well as national guidelines for the treatment of pediatric infectious diseases (i.e., TB, syphilis, etc.). Uptodate is also an excellent in-clinic reference. D. Clinical practice Each resident will keep a log of patients seen during clinic sessions. This serves as a means to ensure reasonable clinic exposure. Likewise, the residents will separately log procedures. (Preceptors should be available for demonstration of unfamiliar skills.) V. EVALUATION The preceptor is encouraged to sit down with the resident on the first day of the clinic orientation to share each other s goals and expectations for the experience. The

6 preceptor should assess the resident s level of knowledge and ability in order to plan for the degree of independence he/she should be allowed during initial patient encounters. Specific practice routines and rules could be shared at this time as well. Short term (one-two months) and long term (six-twelve months) goals should be set. Time should be set aside every three months or so (10 minutes, perhaps at the end of the day) to review the resident s progress to date and re-set goals based on the resident s achievements so far. Every six month, an evaluation of the resident should be filled out be the preceptor and the rotation and preceptor should be evaluated by the resident. These evaluations will be solicited in an electronic format. This curriculum and the clinic sites themselves will be reviewed yearly with special attention paid to written evaluations filled out every 6 months by both resident and preceptors. Feedback will be provided. Modifications are encouraged as needed.

7 Recommended Ambulatory Adult Medicine Topic List abdominal pain injury-extremity Abnormal Pap smear joint/soft tissue pain abuse (elder/spouse) lung nodule, solitary anemia menopause aortic stenosis mitral valve prolapse arthritis, acute nephrolithiasis asthma neurosis/anxiety atrial fibrillation obesity back pain oral lesions breast symptoms osteoarthritis cancer screening osteoporosis chest pain palliative care cholelithiasis pelvic pain chronic pulmonary dis. peripheral neuropathy chronic pain pharyngitis/throat sx. chronic renal failure pneumonia constipation contraception polycythemia coronary artery disease pre-operative evaluation cough/dyspnea prostate disorders BPH, prostatitis DVT/PE proteinuria dementia pruritus depression psoriasis diabetes mellitus rashes, common eruptions diarrhea red eye/glaucoma drugs-pregnancy/nursing seizures dys. uterine bleeding STD eczema sinusitis endocarditis prophylaxis somatization falls in elderly sleep apnea fatigue stasis ulcers GERD substance abuse headaches SVT hearing loss syncope heart failure thyroid nodules hematuria thrombocytopenia hepatitis/abnomal LFT s thrombotic disorders hirsutism TIA/CVA HIV tuberculosis, screening/secondary prevention hoarseness URI hyperlipidemia urinary incontinence hypertension urticaria hypo-/hyperthyroidism UTI /vaginitis immunizations vertigo/dizziness impotence visual loss influenza weight loss

8 Recommended Ambulatory Pediatric Topic List abdominal pain immunizations abuse (child/sexual) infestations - ringworm/lice/scabies ADHD impetigo allergies injury-extremity anemia, iron deficiency joint pain, multiple apnea lead poisoning asthma learning problems behavioral problem lymphadenopathy bronchiolitis mental retardation breastfeeding noisy breathing burns nutrition cerebral palsy obesity chest pain occult bacteremia colic Osgood Schlatter otitis media conjunctivitis pharyngitis contact dermatitis pneumonia constipation/encopresis poisoning/ingestions contraception positional deformities cough pregnancy cryptorchidism proteinuria cystic fibrosis pruritus dehydration puberty disorders depression SCFE developmental delay school readiness diabetes, childhood scoliosis discipline scrotal pain diarrhea/oral rehydration seizure disorder domestic violence sepsis, newborn down syndrome eczema/common rashes STD's eating disorders short stature enuresis sickle cell disease failure to thrive sinusitis fatigue sports participation fever (unknown source) sleep disorders gastroesophageal reflux strabismus growth and development substance abuse head trauma tear duct obstruction headaches thyroid disease hearing loss toilet training heart murmurs tuberculosis, screening/secondary prevention hematuria urinary infections hepatitis vesicoureteral reflux hernias voiding dysfunction hyperlipidemia vomiting hypertension white pupil