VCU Internal Medicine Training Program
Continuity Clinic Resident Curriculum - VCUHS and VAMC
Revision Date: 8/21/09
Revised by: Stephanie Call, MD, Chris Hayes, MD
Purpose
Learning Objectives
How Learning Objectives are Met
Required Reading/Resources
Expectations
Evaluation
Contact
Resident Schedule
Printable version of the curriculum (pdf)
Purpose:
The Continuity Clinic experience prepares residents to care for patients longitudinally in an outpatient setting. This is fundamentally different than any other aspect of residency training. By the completion of training, each resident will be able to:
- Evaluate acute health concerns in an ambulatory setting, including appropriately triaging patients to the emergency department or hospital;
- Deliver high quality, evidence based care for chronic diseases;
- Deliver high quality preventative health care;
- Coordinate care with other health professionals such as specialists, inpatient physician teams, nurses, and other non-physician professionals;
- Provide general internal medicine consultations;
- Use an electronic health record (EHR) to care for a panel of patients.
Internal Medicine residents provide continuity care at two discrete locations, the McGuire VA Medical Center and at MCVH. A resident is assigned at the start of the intern year to one of these two locations. Both locations provide the residents a diverse mix of ages, socioeconomic and ethnic backgrounds, chronic and acute illnesses; this allows the residents to gain experience in diagnosing, evaluating and managing a wide variety of illness and health promotion issues in the longitudinal care setting.
Learning Objectives
Please note that all of the objectives will be demonstrated during patient encounters, oral presentations, discussions; in electronic health record documentation, and during time spent in clinic.
PGY-1
- Patient Care
By the end of the training year, the resident will be able to:- Perform a problem-focused history and physical examination, and develop a management plan in accordance with national guidelines (as available) for patients presenting to ambulatory settings with common acute medical problems such as musculoskeletal pain and upper respiratory tract infections.
- Perform a problem-focused history and physical examination, and develop an evidence-based management plan for ambulatory management of common chronic diseases, such as hypertension, diabetes mellitus, depression, hypothyroidism, and atherosclerosis.
- Develop longitudinal plans of care for patients with acute or chronic medical problems in accordance with national guidelines.
- Identify pertinent United States Preventative Services Task Force guidelines for individual patients and provide patient-centered counseling in ambulatory settings.
- Demonstrate integrity, respect, compassion and empathy for patients and their families, including respect for personal preferences and patient rights.
- Avoid iatrogenic injuries related to medication allergies and drug-drug interactions.
- Give patients accurate instructions regarding medications and follow up care.
- Refill prescriptions at each visit.
- Throughout the year, the resident will ensure that patients have been given a personalized resident business card listing the telephone numbers for appointments and after-hours emergency care.
- Medical Knowledge
By the end of the training year, the resident will be able to:- List differential diagnoses for common acute complaints seen in general internal medicine clinics.
- Describe the risks and benefits of diagnostic and therapeutic strategies for common acute and chronic conditions.
- List ambulatory quality of care indicators for common chronic diseases.
- Exhibit sufficient content knowledge of common, non-urgent conditions to provide care with minimal supervision in the office or by phone.
- Complete all assigned JHILC ambulatory modules
- Exhibit self-motivation to learn.
- Practice-Based Learning and Improvement
By the end of the training year, the resident will be able to: - Admit to errors and seek help in remedying them.
- Identify personal areas of weakness in medical knowledge of ambulatory care, ask for help when needed, and perform focused reading for self improvement throughout the rotation as demonstrated through patient care discussions with preceptors.
- Deliver care that reflects learning from previous experiences.
- Assess patient adherence to treatment regimens and accordingly modify prescribing practices.
- Complete assigned portion of the clinic quality improvement project.
- Use the electronic health record’s decision support tools to enhance patient care as demonstrated within visit documentation.
- Interpersonal and Communication Skills
By the end of the training year, the resident will be able to:- Demonstrate proficiency in the use of oral and nonverbal skills in interactions outside of the context of patient care.
- Establish therapeutic doctor-patient relationships in ambulatory settings with patients from a variety of backgrounds
- Effectively communicate uncomplicated diagnostic and therapeutic plans to patients or their advocates.
- Counsel patients regarding lifestyle behaviors.
- Provide clear, concise oral presentations to preceptors.
- Complete patient charting including an update of histories, problem lists, and medication lists at each visit.
- Work as a productive member of the team with preceptors, nurses/medical assistants, and other office staff.
- Professionalism
Throughout the course of the training year, the resident will/will be:- Honest and trustworthy.
- Punctual, as demonstrated in the completion of assigned tasks and patient care responsibilities, and responding promptly to staff needs (eg, pages and abnormal lab results).
- Demonstrate respect and compassion for all patients.
- Compassionately respond to issues of culture, age, sex, sexual orientation, and disability in patient care.
- Maintain patient confidentiality.
- Demonstrate an interest in providing high quality care.
- Assess and use informed consent.
- Acknowledge errors when they are made and reveal them promptly to the preceptor.
- Demonstrate that his/her prime concern is the patient’s interest and not his/her own.
- Recognize personal responsibility for the safety and well-being of patients, colleagues, and staff.
- Honest and accurate in coding and referral practices.
- Arrange patient coverage for all issues before leaving the hospital for continuity clinic
- Remain in clinic until the end of each session to assist in the evaluation of any Quick Check or walk-in patients
- Engage in self directed learning
- Systems-Based Practice
By the end of the training year, the resident will be able to:- Prescribe medications and order additional testing in compliance with patients’ insurance coverage and medical standards of care.
- Identify sources of support or alternative, lower cost regimens for patients with financial concerns regarding medications.
- Incorporate fundamental cost-effective analysis into care approaches, minimizing unnecessary care.
- Order ancillary services such as home health care, physical therapy, and occupational therapy as medically necessary.
- Communicate with primary care physicians, consultants or referring physicians to improve continuity and quality of care.
- Work well within the core clinic team, including other residents, attending physicians, nurses and pharmacists.
PGY-2
Please note that learning objectives are cumulative and progressive. Therefore, a PGY-2 resident must meet the expectations for an end-of-year PGY-1 resident in addition to those listed below.
- Patient Care
By the end of the training year, the resident will be able to:- Perform a problem-focused history and physical examination
- Develop a management plan in accordance with national guidelines (as available) for patients presenting to ambulatory settings with complex, acute medical problems, such as abdominal or chest pain, or neurological complaints.
- Perform a problem-focused history and physical examination, and develop an evidence-based management plan for ambulatory management of less common chronic diseases.
- Implement patient care contracts for patients using narcotic or other controlled medications on a chronic basis.
- Utilize electronic databases for patient educational materials.
- Remain vigilante for changes in recommendations from federal and professional societies and apply recommendations to their patient population.
- Medical Knowledge
By the end of the training year, the resident will be able to: - Develop well-formulated differential diagnoses for multi-problem patients evaluated in the office or calling with questions/problems.
- Demonstrate understanding and responsiveness to socio-behavioral issues.
- Demonstrate knowledge of statistical principles when reviewing the scientific literature.
- Independently present up-to-date scientific evidence to support hypotheses.
- Practice Based Learning and Improvement
By the end of the training year, the resident will be able to:- Use self-assessments of knowledge, skills and attitudes to develop plans with insight and initiative for addressing areas for improvement in ambulatory care.
- Seeks guidance from attending or scientific literature when unclear on best course of action.
- Uses interactions with nursing staff and other professionals as two-way educational opportunities.
- Interpersonal and Communication Skills
By the end of the training year, the resident will be able to:- Engage patients in shared decision making for ambiguous or controversial scenarios,
- Successfully negotiate most “difficult” patient encounters, such as the irate patient.
- Ensure successful inpatient-outpatient provider communications to maintain appropriate continuity of patient care.
- Professionalism
In addition to the expectations for a PGY-1 resident, the PGY-2 resident will be able to:- Deliver bad news.
- Counsel patients regarding advanced directives and DNR status.
- Deliver high quality care to all patients.
- Demonstrate intellectual curiosity.
- Systems Based Practice
By the end of the training year, the resident will be able to:- Work with staff to assess, coordinate, and improve multispecialty patient care across inpatient and outpatient settings
- Identify additional resources for caring for ambulatory patients, such as home health care agencies, support groups, outpatient treatment centers, and medication assistance programs.
- Guide patients through the complex health care environment.
- Regularly and effectively work with managed care/utilization review personnel, office managers, and other providers within the larger health care system.
- Demonstrates dedication to high quality patient care.
PGY-3
Please note that learning objectives are cumulative and progressive. Therefore, a PGY-3 resident must meet the expectations for an end-of-year PGY-1 and PGY-2 resident in addition to those listed below.
- Patient Care
By the end of the training year, the resident will be able to:- Perform a problem-focused history and physical examination, and develop a management plan in accordance with national guidelines (as available) for patients presenting to ambulatory settings with most acute and chronic medical problems.
- Demonstrate appropriate reasoning in ambiguous situations, while continuing to seek clarity.
- Establish monitoring procedures and demonstrate the ability to change therapeutic programs for ineffectiveness or adverse side effects.
- Use patient education as a form of intervention and partnering.
- Medical Knowledge
By the end of the training year, the resident will be able to:- Regularly display self-initiative to stay current with new medical knowledge.
- Regularly demonstrate knowledge of the impact of study design on validity or applicability to practice.
- Performance Based Learning and Improvement
By the end of the training year, the resident will be able to:- Utilize ambulatory practice data to actively improve practice and patient management when compared to larger populations and Healthy People 2010 goals.
- Interpersonal and Communication Skills
By the end of the training year, the resident will be able to:- Successfully negotiate nearly all “difficult” patient encounters with minimal direction.
- Professionalism
- The objectives are the same as for a PGY-2 resident.
- Systems Based Practice
By the end of the training year, the resident will be able to:- Practice independently in accordance with external regulations and expectations such as E&M coding.
- Allocate resources appropriately to control health care costs while maintaining high quality care.
- Partner with other clinic team members to improve the health care system.
- Assume leadership role in management of complex care plans.
- Every graduating PGY-3 resident will complete end-of-residency patient care notes to facilitate transfer of care to another resident.
How Learning Objectives are met:
- Supervised Direct Patient Care Activities - residents are assigned a continuity clinic half day, with a Clinic Attending supervising no more than four trainees at any given time. Each resident is responsible for primary evaluation of patients and development of initial assessments and plans to be discussed with the Clinic Attending. The Clinic Attending will examine patients at the bedside with the resident as needed based on the Medicare Exception Rule. Residents complete documentation of patient encounters using the electronic health record, order referrals or additional testing as discussed with the attending, and follow up on test results. Case-based teaching centers on data gathering, clinical examination skills, diagnostic and therapeutic plans, and use of the electronic health record.
- Learning Modules - each resident will complete the on-line Johns Hopkins Internet Learning Center (JHILC) modules assigned for the longitudinal ambulatory lecture series. The modules include pre- and post-test self evaluations in addition to didactic content. No minimum passing score is required, but the required number of modules per year must be completed.
- Chart Stimulated Recall – over the course of their first two years in residency the residents will participate in six (6) chart stimulated recall sessions. During their ambulatory rotations as an R1 and R2, the residents will participate in a Chart Stimulated Recall session with one of the Chief Medical Residents. During these sessions, a resident’s clinic notes will be reviewed, with the resident, and they will receive feedback on ways to improve their note and help them with efficiency in the outpatient setting.
- Quality Improvement Project - every resident will participate in clinic quality improvement projects. The ambulatory curriculum Associate Program Director and the ambulatory CMR will coordinate with continuity clinic representatives and preceptors to select, organize and implement the projects.
- E&M Coding - further knowledge about E&M coding, the resident will work with the clinical preceptor to enter E&M codes for patient visits
- Independent Reading - each resident will read independently to answer questions about patient care that arise in clinic. The resident may use primary literature or other resources suggested by preceptors.
- Each resident is required to follow the expectations outlined for Internal Medicine Residency Partners
- Supervised performance of ambulatory procedures
Required Reading/Resources:
- Health prevention and screening guidelines – as outlined in clinic orientation
- Other specific readings will be assigned by supervising clinical faculty members and fellows. In addition, it is expected that housestaff read articles that are relevant to the patients they see, including articles generated through literature searches. Residents should become familiar with national and hospital guidelines for care of common medical disease states.
- Johns Hopkins Medicine Web-Based Ambulatory Care Curriculum
Expectations:
- Attendance / Punctuality. Call the CMR on call ASAP to report acute illness or personal / family emergency requiring absence
- Professional behavior at all times with staff, peers, consultants, patients and families
- Attendance at Internal Medicine required conferences
- Completion of required Johns Hopkins web-based curriculum
- Participation in QI project
Evaluation:
- Supervising clinic physicians will evaluate residents electronically via New Innovations twice yearly. These evaluations should be discussed in person with the resident. There should be regular formative feedback from supervising attendings regarding performance.
- Residents will evaluate supervising attending faculty electronically via New Innovations twice per year.
- Housestaff log procedures performed via New Innovations. Attendings, or other supervising physicians, documents satisfactory performance through the electronic procedure logger.
- Clinic staff will evaluate residents twice yearly in New Innovations – using nursing evaluation (new 2007-08)
- Documented completion of required Hopkins web-based modules. Failure to complete will result in reduced evaluation in professionalism and PBL on final clinic evaluations.
Contact:
- Ambulatory Chief Medical Resident – 828-5163
- Ambulatory Associate Program Director, Dr. Bennett Lee – 828-9726
- MCVH ACC Clinic Director – Dr. Denise Borden
- VAMC Resident Continuity Clinic Director – Dr. Harriet Foster
Resident schedule:
- See individual schedule – New Innovations
