CURRICULUM on PGY2 AMBULATORY CARE ROTATION UC Davis Internal Medicine Residency Program Lead Faculty Members: Darin Latimore, MD Tonya Fancher, MD MPH I. Educational Purpose and Goals By the end of this rotation, the second year resident will have a working knowledge of common ambulatory problems within the medical specialty clinics of Gastroenterology, Hematology and Oncology, Nephrology, Endocrinology, Rheumatology, Infectious Disease, Pulmonary, Cardiology and Geriatrics. The resident will be able to perform a focused history and physical examination for patients seen in these medical subspecialties, order cost-effective diagnostic testing, formulate evidence-based management plans and have a working knowledge of appropriate referrals to these clinics. Further, the second year resident will be able to locate, retrieve and systematically evaluate scholarly articles related to patient care, identify and discuss medical errors through reviewing multiple articles and active pieces of legislation the resident will develop an understanding of health care policy questions that are pertinent today. II. Principal Teaching Methods A. Supervised Direct Patient Care: Residents primarily learn through direct patient care with attending supervision in the outpatient setting. Residents will be responsible for primary evaluation of patients and development of an initial assessment and plan that is discussed with the faculty preceptor. The resident will complete documentation of patient encounters (within the electronic health record or as specified by county, Kaiser or VA-based preceptors), discuss key features of the patent s presentation, assessment and plan with the attending, and notify the patients referring physician of the patient s visit. Case based teaching will center on data gathering, clinical examination skills, diagnostics and therapeutic plans, and use of the electronic health record. When appropriate, the resident will perform procedures under direct supervision. B. Didactic Lectures: The resident will participate in the mandatory weekly pre-clinic journal clubs, Monday afternoon conferences and the weekly ambulatory care workshops. C. Learning Modules: The resident will complete: 1. Journal club presentation including a written summary and validity assessment 2. Each didactic session the residents will review and present at least one article on a public health topic. 3. Resident will videotape themselves with patient/actor leading the patient through a discussion on Diabetes Management. The video will be reviewed with the group at one of the didactic sessions. This will be considered one of your mandatory CEX during this rotation. 4. Practice Based Learning and Improvement Project: The resident will be assigned one of two ABIM Practice Improvement Modules (hypertension or preventative care). The resident will complete a chart review on five patients from their continuity clinic panel and participate in reviewing the data and creating a practice improvement project for the resident clinic. C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc
The resident will certify completion of the modules through completion of the Ambulatory Block Summary Document and by providing a copy of: EBM module; Health Care Policy chapter answers to questions; journal club presentations; CEX s; SIMS Suite; and hypertension chart reviews. D. Independent Reading: The resident will read independently to answer questions about patient care that arise in clinics. The residents may use UptoDate, primary literature or other sources suggested by preceptors. III. Educational Content A. Mix of Diseases: 1. General Internal Medicine: In their continuity clinics, the resident will encounter patients with a broad range of acute and chronic medical conditions, including but not limited to diabetes, hypertension, coronary heart disease, congestive heart failure, arthritis, obesity, depression and anxiety disorders, hyperlipidemia, abnormal uterine bleeding, osteoporosis, upper and lower respiratory infections, allergic rhinitis, peptic ulcer disease and gastroesophageal reflux disease, anemia, chronic obstructive pulmonary disease, asthma, and chronic renal failure. 2. Subspecialty clinics: Clinical care will focus on diseases specific to that specialty clinic and which are the most useful for general internists. The most common illnesses include thyroid disease, osteoporosis, hormone deficiencies and excesses, arthritis, SLE, fibromyalgia, depression, personality disorders, schizophrenia as well as a variety of sports related injuries. a. Hematology/Oncology: Residents will be exposed to a broad range of acute and chronic medical conditions, including but not limited to hematologic and oncologic problems such as blood dyscrasias, heritable blood disorders, lung, breast and prostate cancers. b. Gastroenterology: Residents will be exposed to a broad range of acute and chronic medical conditions, including but not limited to inflammatory bowels diseases, the hepatitidies, irritable bowel syndrome, gastritis and screening for colon cancer. c. Nephrology: Residents will be exposed to a broad range of acute and chronic medical conditions, including but not limited to chronic kidney diseases stages 1-5, nephritic syndrome, glomerulonephritis and renal replacement therapy. d. Infectious Disease: Residents will be exposed to a broad range of acute and chronic medical conditions, including but not limited to osteomylelitis, HIV/AIDS, tuberculosis and abscess care. e. Pulmonary: Residents will be exposed t a broad range of acute and chronic medical conditions, including but not limited to asthma, COPD, emphysema and interstitial lung diseases. f. Cardiology: Residents will be exposed to a broad range of acute and chronic medical conditions, including but not limited to congestive heart failure, angina, hypertension, and congenital heart diseases. g. Endocrinology: Residents will be exposed to a broad range of acute and chronic medical conditions, including but not limited to thyroid diseases, diabetes, hirsuitism and hypogonadism. C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc 2
h. Rheumatology: Residents will be exposed to a broad range of acute and chronic medical conditions, including but not limited to SLE, rheumatoid arthritis, osteoporosis and osteoarthritis. i. Geriatrics: Residents will be exposed to a broad range of acute and chronic medical conditions including but no limited to performance of a complete geriatric assessment, dementia and delirium, falls risk assessment and hospice care. B. Patient Characteristics: Through the experience in three different hospital systems (UC Davis, Kaiser, VA and Sacramento County), the residents care for patients with great diversity of age, gender, occupation, culture, socioeconomic status, and ethnicity. C. Learning Venues: 1. Location: This is a purely ambulatory rotation. The residents will rotate with preceptors at the UCD Ambulatory Clinics, UC Davis satellite clinics, Kaiser clinics, VA clinics and the Sacramento County Clinics. 2. Types of clinical encounters: The resident will see patients for new consultations, follow up appointments for chronic medical conditions, acute care visits, and for outpatient procedures. 3. Longitudinal Conferences: the resident will continue to participate in regularly scheduled conferences including grand rounds and Monday core conferences. 4. Longitudinal Clinic: the resident will continue to participate in his/her weekly continuity clinic. 5. Procedures: availability of procedures will vary based on patient characteristics but may include: a. Bone marrow biopsy, peripheral smear b. Colonoscopy, upper endoscopy c. Peripheral dialysis access catheter placement d. Lumbar puncture, abscess drainage e. Bronchoscopy, pulmonary function testing, spirometry f. Exercise stress testing g. Thyroid biopsy, nuclear imaging of thyroid disease h. Arthrocentesis/joint injection D. Structure of Rotation: Below is a sample schedule. The actual schedule may vary from month to month based on preceptor availability. Continuity clinic will be substituted on two afternoons for each resident. The sequence of specialties will vary, based on availability. 1. Orientation: The resident will meet with Dr Latimore for orientation at 8 AM on the first Wednesday of the rotation. 2. Start times: The resident should be present at the preceptors office and ready to see patients at 8AM and 1PM (or 830 and 130 if at Kaiser), respectively, for morning and afternoon assignments. 3. Self study time: Study sessions should be used to complete rotation requirements. 4. Night Float: residents will spend at most one weekend night on night float at UCDMC. 5. Leave: Residents may elective to take the fourth week of the block as leave time. C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc 3
Week Time Monday Tuesday Wednesday Thursday Friday Sat/Sun 1 8 am Clinic Clinic Conference GR/clinic clinic 1 pm Conference Self study Clinic clinic clinic 2 8 am Hospice Clinic Conference GR/self study Geriatrics 1 pm Conference Geriatrics Geriatrics Geriatrics Geriatrics Night float 3 8 am Clinic Clinic Conference GR/clinic Self study 1 pm Conference clinic clinic clinic clinic 4 8 am Clinic Clinic Conference GR/clinic clinic 1 pm Conference clinic Self study clinic clinic IV. Principal Ancillary Educational Materials A. Computer-based Resources: available for online texts, clinical guidelines, and literature searches at multiple sites in the hospital and clinics and available at https://ucdcrc.ucdmc.ucdavis.edu/servlet/crcsignin B. Textbooks are available in most clinic settings. There is a full medical library on the UC Davis Medical Center campus. C. Evidence-Based Medicine: Each intern is provided with a personal copy of Evidence- Based Medicine: How to Practice and Teach EBM, Second Edition 2000, by David Sackett et al. D. The following web-based resources are available for resident review: 1. Duke University Medical Center s Introduction to Evidence Based Medicine available at: http://www.mclibrary.duke.edu/subject/ebm?tab=overview&extra=tutorials 2. Duke University Supplement on diagnostic tests available at: http://www.hsl.unc.edu/services/tutorials/ebm/supplements/eviddiagnosis.htm 3. The University of Nebraska Medical Centers module on Interpreting Diagnostic Tests at http://gim.unmc.edu/dxtests/default.htm 4. Michigan State University s Introduction to Information Mastery available at: http://www.poems.msu.edu/infomastery/default.htm 4. The Centre for Evidence Based Medicine at http://www.cebm.utoronto.ca/ 5. The Users Guide to Medical Literature at http://ugi.usersguides.org/usersguides/hg/hh_start.asp 6. The Joint National Committee (JNC7) guidelines on hypertension at http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm 7. National Cholesterol Education Project (NCEP) guidelines at http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm 8. The United States Preventative Services Task Force recommendations at http://www.ahrq.gov/clinic/uspstfix.htm 9. The Agency for Health Research and Quality catalog of evidence-based practice recommendations at http://www.ahrq.gov/ 10. Mooradian et al. Narrative Review: A Rational Approach to Starting Insulin Therapy Annals of Internal Medicine 2006; 145:125-134. C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc 4
11. Chapters from Health Politics Power, Populism and Health (Please note each chapter has list of references and web-based resources.) 12. Chapters from The Politics of Public Health in the United States (Kant Patel and Mark Rushefsky). V. Methods of Evaluation A. Resident Performance: 1. Journal Club, Dr Latimore will assess performance on the above measures using institutional assessment tools. Individualized remediation will be provided as needed. 2. Video tape review/cex of Diabetes Management 3. Health Care Policy Curriculum 4. ABIM Practice Improvement Module Chart Review The resident will perform a chart review of 5 of their patients using the ABIM PIM forms. Results will be entered into the on-line database in prior to completion of the block. Completion is required to receive a passing evaluation for the rotation. 5. Competency Evaluations Faculty provide formative feedback on clinical performance, including documentation, throughout the rotation. At the end of the rotation, preceptors provide summative feedback by completing web-based electronic resident evaluation forms provided by the Internal Medicine Residency office. The evaluation is competency-based, fully assessing core competency performance. The evaluation will be shared with resident, is available for on-line review by the resident at their convenience and is sent to the residency office for internal review. The evaluation will become part of the resident file and will be incorporated into the semiannual performance review for directed resident feedback. B. Program and Faculty Performance 1. Upon completion of the rotation, the resident will be asked to complete a service evaluation form commenting on faculty, facilities and service experience. These evaluations will be sent to the residency office for review and the rotation coordinator (Dr Fancher) will review anonymous copies of completed evaluation forms periodically. VI. Institutional Resources: Strengths and Limitations A. Strengths 1. Faculty: Faculty members are expert in their fields and have demonstrated that they are competent and enthusiastic educators. 2. Settings: Residents will be exposed to a mix of academic and county settings. The facilities are generally technologically sophisticated and appropriate to the field. 3. Patients: Residents will see patients from a variety of socioeconomic and ethnic backgrounds with a mixture of acute and chronic complaints. 4. Evaluation tools: Evaluations methods include written competency based assignments and self-evaluation exercises B. Limitations 1. Settings: The resident must travel between practice settings. County settings may not have the same electronic resources available to residents. 2. Faculty: The resident may work with a preceptor only a few times. C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc 5
3. Due to the technical aspects of some of the care delivered by these preceptors, residents may act as observers some of the time. VII. Rotation Specific Competencies A. Subspecialty Clinics 1. Patient Care: By the end of the rotation, the resident will be able to: a. Perform a problem- focused history and physical examination for patients who present to each of the specialty clinics. b. Develop an evidence-based management plan for these patients. c. Identify appropriate referral and evaluations plans. d. These skills will be demonstrated directly during patient encounters, 2. Medical Knowledge: By the end of the rotation, the resident will be able to: a. List the common presenting complaints common diseases within each subspecialty. b. Describe the risks and benefits of diagnostic and therapeutic strategies within each subspecialty. c. This knowledge will be demonstrated directly during patient encounters, 3. Interpersonal and Communication Skills: By the end of the rotation, the resident will be able to: a. Establish therapeutic doctor-patient relationships on ambulatory settings. b. Effectively communicate with all members of the medical team. c. Provide clear, concise oral presentations to preceptors d. Complete patient charting using the forms in the electronic health record. All charts must be completed by the resident and send to the preceptors within 48 hours of care e. Work as a productive member of the team with preceptors, nurses, medical assistants and other office staff. f. These skills will be demonstrated directly during patient encounters, 4. Professionalism: Throughout the rotation, the resident will demonstrate appropriate professional behaviors with all members of the medical team. The resident will: a. be timely b. Treat all patients and their families with compassion and respect c. Acknowledge errors when they are made and reveal them promptly to the preceptor d. Tell the truth e. Maintain patient confidentiality f. be honest and accurate in coding and referral practices g. Demonstrate an interest in proving high quality care 5. Practice Based Learning By the end of the rotation, the resident will be able to: a. Identify personal areas of weakness in medical knowledge of ambulatory specialty care and perform focused reading for self-improvement throughout the rotation. b. demonstrate critical appraisal skills and use of information technology. C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc 6
c. This learning will be demonstrated directly during patient encounters, 6. Systems Based Practice By the end of the rotation, the resident will be able to: a. Triage patients to treatment within primary care or referral for specialty care. b. Communicate with primary care physicians, consultant or referring physician to improve continuity and quality of care. B. Geriatrics 1. Patient Care: By the end of the rotation, the resident will be able to: d. Perform a problem- focused history and physical examination for geriatric patients. e. Develop an evidence-based management plan for the following conditions: I. dementia II. delirium III. urinary incontinence IV. falls V. cancer screening in the elderly f. Identify appropriate referral and evaluations plans for geriatric patients. d. These skills will be demonstrated directly during patient encounters, 2. Medical Knowledge: By the end of the rotation, the resident will be able to: d. List the common presenting complaints for the diagnoses listed above e. Describe the risks and benefits of diagnostic and therapeutic strategies for the a conditions listed above f. This knowledge will be demonstrated directly during patient encounters, 3. Interpersonal and Communication Skills: By the end of the rotation, the resident will be able to: g. Establish therapeutic doctor-patient relationships on ambulatory settings. h. Effectively communicate with all members of the medical team. i. Provide clear, concise oral presentations to preceptors j. Complete patient charting using the forms in the electronic health record. All charts must be completed by the resident and send to the preceptors within 48 hours of care k. Work as a productive member of the team with preceptors, nurses, medical assistants and other office staff. l. These skills will be demonstrated directly during patient encounters, 4. Professionalism: Throughout the rotation, the resident will demonstrate appropriate professional behaviors with all members of the medical team. The resident will: h. be timely i. Treat all patients and their families with compassion and respect j. Acknowledge errors when they are made and reveal them promptly to the preceptor k. Tell the truth l. Maintain patient confidentiality m. be honest and accurate in coding and referral practices n. Demonstrate an interest in proving high quality care C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc 7
5. Practice Based Learning By the end of the rotation, the resident will be able to: d. Identify personal areas of weakness in medical knowledge of ambulatory specialty care and perform focused reading for self-improvement throughout the rotation. e. demonstrate critical appraisal skills and use of information technology. f. This learning will be demonstrated directly during patient encounters, 6. Systems Based Practice By the end of the rotation, the resident will be able to: a. Triage patients to treatment within primary care or referral for specialty care. c. Communicate with primary care physicians, consultant or referring physician to improve continuity and quality of care. VIII. Work Hours A. During this rotation, shifts are 12 hours or less and there is no in-house call activity. The schedules are arranged so that there are greater than 10 hours between all shifts. All residents get a minimum of 1 in 7 days free from responsibilities averaged over the four week rotation. Duty hours are limited to less than 80 hours per week. C:\Documents and Settings\cflanders\Desktop\Curricula\4-Amb Care Curriculum PGY2 06-17-08.doc 8