University of California, Irvine
Department of Medicine
Internal Medicine Residency Program Rotation Curriculum
I.
Rotation Sites and Supervision
Rotation Name: AMBULATORY BLOCK at LBVAMC
Site
LBVAMC
Faculty Supervisor
Susan Sandor, MD, PhD
Zsuzsanna.Sandor@med.va.gov
Administrator
Teri Lynn Wheeler
Phone
562-826-8000 ext
3832
Faculty participating in the rotation:
Continuity clinic supervision:
Hiva Bastanmehr
Nolan Cordell
Shanti Iyer
Lawrence Lerno
James Rick
Zsuzsanna Sandor
Anthony Vo
II.
Description of Rotation /Educational Experience
Ambulatory rotation is a core requirement for first and second year residents in internal medicine
residency training.
Rotation is designed to provide knowledge and experience to the resident in taking care of
patients with common chronic diseases as well as in caring for patients with acute onset medical
conditions.
The block is a combination of Primary Care Clinic, Urgent Care, Subspecialty clinic and Pre –op
clinics.
Residents will develop understanding of appropriate referral to the subspecialty clinic, gain insight
and experience in the operational process of subspecialty clinic, walk in and pre-op clinics.
Residents should present every case to a faculty member who supervises care in the given setting.
Residents will attend clinic at the following different outpatient care areas:
•
Continuity clinic
•
Same day clinic
•
Sub- specialty clinics: Cardiology, Renal, Pulmonary etc.
•
Pre –op clinic
Resident should attend Academy of Medicine as part of the ambulatory block experience.
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III.
The principal teaching methods for this rotation
• Clinical teaching
• Faculty mentoring and role modeling
• Didactic lecture series on internal medicine related topics
IV.
Responsibilities for PGY1 residents (interns), PGY2 residents and attendings on this
rotation
Morning meetings: 8:00-9:00 am. Note that interns and residents who have morning PCC will not
attend morning meetings on the day of their PCC which starts at 8:30am
Weekly time assignment:
• Continuity clinic: 2 half days
• Same day clinic: 1-2 half day
• Subspecialty clinics: 2-3 half days
• Academy of Medicine: 1 half day
• Pre-op clinic: 1 half day
V.
VI.
Curricular Goals
a. To enable residents to provide state of the art, compassionate and professional care
for patients in outpatient setting through applying the latest medical knowledge.
b. To train resident in providing longitudinal care with emphasis on prevention and
heath maintenance in a cost effective, patient centered way.
c. Gain experience in coordinating patient care within the healthcare team,
among different/subspecialty services, using available resources.
d. Gain experience in designing and completing PI projects with the help of the
mentor
VII.
Competency-based Objectives for the VA Ambulatory Clinic Rotation
a. Resident will be able to develop an appropriate state of the art plan of management
and treatment based on their evaluation of the patient.
b. Resident will be familiar with all the gender & age appropriate health maintenance and
prevention methods and demonstrate their use.
c. Resident will master the usage of computer assisted reminder system for screening procedure
and will treat their patients according to the current goals established by the latest guidelines.
d. Resident will be able to identify the appropriate level of care for a given patient, evaluate
the need for referral to subspecialty service and make the appropriate referral if needed.
e. Resident will be able to work together with other services developing interdisciplinary
approach on a patient centered way.
f. Resident will be able to appropriately and effectively educate patients about their
health problems and needed health maintenance.
g. Resident will be able to access and apply evidence bases recourses in patient care.
h. Resident will be able to demonstrate appropriate professionalism and humanistic
approach to the patient.
i. Resident will be familiar with the operational processes of the clinic: to write
appropriate notes and select encounter information, knowing the scheduling
process, be able to adequately utilize ancillary services.
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Patient Care
PGY1
PGY2
PGY3
Complete medical data base (H&P) relevant
to this discipline and good patient care overall
Reporter &
Interpreter
Manager & Educator
Diagnostic decision making based upon the
best evidence
Reporter &
Interpreter
Manager & Educator
Competent at the level
of a well-trained
internist
Competent at the level
of a well-trained
internist
Involving patients in decisions about their
care
Working with other health care professionals
to ensure the best care
Teaching patients and families
Patient triage and evaluation of severity
Most of the time
All of the time
All of the time
All of the time
All of the time
All of the time
Most of the time
Reporter &
Interpreter
All of the time
All of the time
Manager & Educator Competent at the level
Response to emergencies
Reporter &
Interpreter
Manager & Educator
Commitment to wellness, screening &
prevention.
Identification & intervention in psycho-social
issues, including domestic violence &
depression
Most of the time
All of the time
All of the time
Most of the time
All of the time
All of the time
Medical Knowledge
PGY1
Medical illnesses
Reporter &
Interpreter
Reporter &
Interpreter
Reporter &
Interpreter
Complete differential diagnoses
Epidemiology & biostatistics
Research design
Ambulatory medicine
Recognizing own limitations
Reporter &
Interpreter
Reporter &
Interpreter
All of the time
Practice-based Learning
PGY1
Take advantage of patient care by reading
Use of medical information resources &
search tools
Inspiring others to use Evidence-based
resources and make EBM-based decisions
Applying critical appraisal techniques
consistently to patient resources for
patient care
Consistently
Consistently
Interpersonal & Communication
Skills
PGY1
Create personal relationships with each
patient by appropriately engaging them at
each encounter
Most of the time
ICU Medicine
PGY2
Manager &
Educator
Manager &
Educator
Manager &
Educator
Competent in basic
issues
Manager &
Educator
Manager &
Educator
All of the time
PGY2
of a well-trained
internist
Competent at the level
of a well-trained
internist
PGY3
Competent to practice
independently
Competent at the level of a
well-trained internist
Competent at the level of a
well-trained internist
Competent in basic
issues
Competent at the level of a
well-trained internist
Competent at the level of a
well-trained internist
All of the time
PGY3
Consistently
Consistently
Consistently
Consistently
Basic understanding Consistently
Consistently
Basic understanding Consistently
Consistently
PGY2
All of the time
PGY3
All of the time
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Use of verbal & non-verbal facilitation
Consistently demonstrate appropriate
empathy & good listening skills
Respectful communication with colleagues &
other professionals
Involve patients & families in discussions
about care, including patient education.
Ensure that patients get the best possible
care
Enlist patients & families in health care
decisions, including their feedback
Ability to accept & integrate feedback
from faculty & peers
Most of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
Most of the time
All of the time
All of the time
All of the time
All of the time
All of the time
Most of the time
All of the time
All of the time
All of the time
All of the time
All of the time
Professionalism
PGY1
Altruism: patients needs above their own
Confidentiality (including HIPAA)
Ethical behavior
Commitment to excellence
Sensitivity to age, gender, gender-preference,
ethnicity, culture & disability
Awareness of duty hours, fatigue in myself &
others, & other outside stresses, including
substance abuse & finances
Commitment to education & to learning
Personal insight & self-reflection
Completion of assignments
Timely response to pages
Timely completion of medical records
Conference attendance
Hand-offs and sign-outs
Most of the time
All of the time
All of the time
All of the time
Most of the time
Most of the time
All of the time
All of the time
All of the time
All of the time
Most of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
All of the time
Consistently of the
highest quality
Consistent
Accelerated
All of the time
All of the time
All of the time
All of the time
All of the time
Consistently of the
highest quality
Consistent
PGY3
PGY3
Leadership skills
All of the time
Most of the time
All of the time
All of the time
All of the time
Meets requirements
Consistently well
presented
Developing
Systems-based Practice
PGY1
PGY2
Cost-effectiveness
Generally aware
Integrates into all
plans
Integrates into all
plans
Use of outside resources
Generally aware
Consistently of the
Consistently of the
Use of case-management
Generally aware
highest quality
highest quality
Attention to quality, safety, and process
improvement
Generally aware
Integrates into all
plans
Makes these a top
priority in all areas
Systems-based Practice (continued)
PGY1
PG2
PGY3
Identification of systems issues that affect
patient care
Use of the incident reporting systems to
identify systems issues
Understanding of the business of medicine,
health care systems, & public policy
Developing
Consistently
Consistently
Developing
Consistently
Consistently
Developing
Generally aware
Sophisticated
understanding
Teaching Skills
PGY1
PGY2
PGY3
PGY3
4
Commitment to teaching
Strong commitment Strong commitment
Use of the microskills of teaching
Understanding of the teachable moment
Patience with learners
Conference presentation
Patient education & adherence
Generally aware;
expresses
importance
Developing
Developing
Developing
Developing
Basic
Organization Skills
PGY1
PGY2
Patient care organization systems & practice
Uses systems
Ability to prioritize personal issues in accord
with personal values & priorities (Get my life
in order)
Ability to help others get organized
Organizing for study, reading, & life-long
learning
Organizing teams to include & prioritize
learning & teaching
Organizing to obtain & prepare for careers or
fellowships
Basic understanding
Fully integrated;
multi-tasks easily
Consistent focus
Fully integrated;
multi-tasks easily
Consistent focus
Advisor
Competent &
committed
Competent &
committed
Competent
Educator
Competent &
committed
Competent &
committed
Competent &
committed
Conscious of
necessity
Aware
Skilled
Skilled
Skilled
Basic
Clearly competent
Skilled
Skilled
Skilled
Skilled
Clearly competent
PGY3
VIII. Level of Responsibility
a. Resident is responsible for the initial evaluation of each patient, performing a case
appropriate physical exam and developing an appropriate diagnostic and treatment
plan and presenting the case to the assigned faculty.
b. Residents are responsible to write adequate electronic note (CPRS) for each clinical
encounter in a comprehensive and timely manner (closing note by the end of the
clinic day) and send their note to the supervising faculty member for co-signature.
c. Residents are responsible to address all the active clinical reminders, ordering the
appropriate health maintenance and screening procedures for the patients.
d. Residents are responsible to order/fill patients medication and to make sure
patient has enough supply until the next visit.
e. Residents are responsible to follow up and take action on all abnormal laboratory
values and imaging needing attention by checking their view alerts in a timely
manner.
f. Resident should take full responsibility in the care of their assigned patients.
g. Residents are to respond to all pages from clinics in a promptly manner.
h. Resident should attend all conferences along their continuity clinic training.
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IX.
Teaching Methods
a. Practice Based Learning
1. Self- directed, case based learning
Residents must take initiative for self-learning and problem-solving and demonstrate the
ability to investigate and evaluate their care of patients. Residents must be able to locate,
appraise and utilize evidence from scientific studies, and to continuously improve patient
care based on self-evaluation.
2. Case based teaching
Residents will participate in case based discussion prompted by their presentation to the
faculty.
3. Feedback based teaching
a. Resident will be given feedback on a case by case basis every week.
b. Resident must be able to incorporate formative evaluation feedback into daily
practice.
b. Systems Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and
system of health care, as well as the ability to call effectively on other resources in the system
to provide optimal health care.
1. Residents must be able to incorporate considerations of cost awareness and risk-benefit
analysis in patient care.
2. Resident must advocate for quality patient care and optimal patient care systems.
X.
Specific Topics Addressed in the Curriculum
a. Management of common chronic diseases:
- Diabetes mellitus
- Coronary artery disease
- Heart failure: systolic & diastolic
- Hypertension
- Hypercholesterolemia
- Acute and chronic kidney failure
- Liver failure
- Obesity
- Degenerative joint disease
- Osteoporosis
- Chronic anticoagulation
- Benign prostate hypertrophy
- Anemia
b. Management of common acute conditions:
- Urinary tract infection
- Upper respiratory tract infection: bronchitis/pneumonia
- Conjuctivitis
- Acute musculoskeletal symptoms
- Otitis media and externa
- Sinusitis – viral/bacterial/allergic
- Skin rashes/allergic reaction
- Deep venous thrombosis
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c. Operation of the clinic, business of medicine
d. Health maintenance and screening procedures – age and gender appropriate
XI.
Diagnostic Skills and Procedures
As needed for providing care in the different clinics listed above.
XII.
Evaluation Tools
a. Direct observation
b. Feedback given by supervising faculty on a weekly basis
c. Faculty evaluation
d. Number of performance measure met/ unmet
e. Patient satisfaction surveys
XIII. Competencies & Assessment Method (Residents)
Evaluation Method
Direct
Observation
Report or
Presentation
E-note Performance Compliance
with follow ups
review measures
Competency
X
Patient Care
X
X
X
Medical
Knowledge
X
X
X
Practice-based
Learning
Communication
Skills
Professionalism
X
X
X
X
X
X
X
X
X
Systems-based
Practice
Teaching Skills
X
X
X
X
X
X
X
X
X
X
XIV. Assessment Method (Program Evaluation)
Rotation and faculty evaluation form completed by the Residents.
XV.
Educational Resources
A. Websites
1. United states preventive services taskforce : www.uspstf.org
2. Health care policy, the “access project”: www.accessproject.org
3. Other – forms for calculation: hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof
4. National guideline clearing house : www.guideline.gov
5. Ovid medline: http://gateway.ovid.com (no password needed from VA)
B. Guidelines
1. Hypertension: www.nhlbi.nih.gov/guidelines/hypertension/
2. Cholesterol: www.nhlbi.nih.gov/guidelines/cholesterol/
3. Cancer screening: www.ahrq.gov/clinic/uspstfix.htm
Updated June 2014
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