Revised June 5, 2009
Goals and Objectives
Ambulatory Block Rotation 2009-2010
Rotation Coordinator:
Aditi Singh, M.D.
Department of Internal Medicine
University of Nevada School of Medicine
Suite 300, 2040 W. Charleston Blvd.
(702) 671-2345
OVERVIEW
Educational Purpose
The ambulatory block is a four-week rotation designed to provide residents with education and
experience in outpatient medicine as well as non-medicine subspecialty services. The ambulatory
block includes rotations in ENT, Urology, Pain Management, Neurology, Pulmonary, Female
Health Clinic, and COPD Clinic. At the start of the rotation, each resident receives an orientation
including a description of the rotation, teaching conferences with the individual presentation dates,
and a calendar for the month showing a daily listing of the scheduled rotations.
This rotation will also provide residents with the opportunity to participate in coordination of care
across health care settings. Residents will review and appropriately manage laboratory results on all
clinic patients undergoing laboratory testing. Residents will have several ambulatory clinic sessions
where the resident may encounter acute care issues of peers’ patients. Additionally, with faculty
guidance, residents will manage urgent patient problems between outpatient visits. Supervision is
provided by faculty as well as subspecialty physicians.
The overall objective of the ambulatory experience is for the resident to develop the knowledge,
skills, and attitudes of competent internists so that he or she may diagnose, manage, and
appropriately refer patients presenting with common outpatient problems. Learning occurs through
supervised direct patient care clinical experiences, self-directed learning, and didactic conferences.
Teaching Methods
Direct Supervision of Patient Care
The resident will be under the supervision of faculty and subspecialty physicians who will oversee
the care of the patients and provide clinical teaching centered around each encounter in the Lied
Clinic and Total Life Care. The resident will obtain the initial data, write a note, and present the
patient to the attending physician. The attending will fully review each patient interaction and teach
about the case. The resident and attending will collaborate on medical decision making, with an
increasing role by the resident. The resident will then dictate the patient note with a summary of the
visit, including the final plan.
Experiences are provided in medically underserved clinics and subspecialty clinics. Patients present
from a broad range of socioeconomic backgrounds, ages, and levels of acuity.
Residents will also manage urgent patient problems between outpatient visits, discuss the scenario
and plan with faculty, and dictate a summary of the encounter.
Structured Didactics
Ambulatory block residents are expected to attend morning reports and noon conferences.
Residents will be assigned reading topics based on clinical encounters. The resident and attending
will review and discuss any required reading.
Special Projects
The ambulatory resident will be required to facilitate two pre-assigned ambulatory morning reports
each block. One morning report may be any topic in outpatient medicine. Ideally, the resident
should select an interesting case encountered during the rotation, and present the case followed by a
discussion of the topic. The second morning report will in an educational prescription format. The
resident will locate, appraise, and assimilate evidence from studies relating to his or her clinical
encounters.
The ambulatory resident will be required to complete an “Ambulatory Learning Tip of the Week”
by the end of the rotation.
Self-Directed Learning
There will be protected time for self-directed learning, during which residents can read and reflect
about patient encounters.
Residents are expected to independently research care for their patients using resources available on
the UNSOM Savitt Library, which is available online.
Residents must complete the Coding 101 online multimedia curriculum, available at
http://www.sitemaker.umich.edu/coding101.
Mix of Diseases
The patients seen will represent a very wide spectrum of medical problems commonly encountered
in an ambulatory general internal medicine practice. Additionally, residents will be exposed to
various subspecialty rotations during which they will be exposed to common clinical problems in
the respective subspecialty. In both venues, the type of encounters range from well visits for
preventative medicine and health maintenance to acute visits and follow-up visits for chronic
diseases.
Patient Characteristics
The patient population is diverse, representing a broad mix of age, gender, and ethnicity, from all
social and economic strata. UMC and its affiliated continuity clinic serve primarily the indigent
population of Clark Country.
Types of Clinical Encounters
Patient encounters are in the outpatient setting at the Lied Ambulatory Clinic and at Total Life Care.
Encounters at these settings will include scheduled visits, acute ambulatory visits, and subspecialty visits. In
scheduled and acute ambulatory visits, the resident may encounter patients from his or her peers’ healthcare
panel. The resident is responsible for dictating a summary on each visit.
In all instances, residents will have first contact with the patients and will be supervised by the attending
physician.
Close interaction with various other healthcare team members including clinic nurses, pharmacists, social
workers, home health agencies, and medical equipment companies occur regularly.
Procedures
Breast examination
Pelvic examination
Rectal examination
PAP smears
Wet preps
Skin biopsy
Resident Supervision
Residents have constant on site supervision as well as daily personal supervision in their patient
care. The rotation will be under the supervision of the attending. The resident will see patients as assigned
by the attending, write initial and follow up notes, and review them with the attending.
Didactic Teaching
Morning Report
Ambulatory block residents are required to maintain greater than 60 % attendance at
morning report. Morning Report begins at 8 a.m. on Monday through Thursday and at 8:30
a.m. on Friday. Each week, there is one morning report dedicated to ambulatory education.
Noon Conference
Ambulatory block residents are required to maintain greater than 60 % attendance at noon
conference. Noon conference occurs daily, Monday through Friday. These sessions cover
the basic core curriculum, and other curriculum topics such as ethical issues, geriatrics,
computer systems and informatics, health care systems, occupational and environmental
health issues, and other topics of concern.
Core Reading Materials
Harrison’s Principle’s of Internal Medicine, 17th ed., Kasper DL, ed. McGraw Hill
The Washington Manual of Medical Therapeutics, 32nd ed.
Principles of Ambulatory Medicine, 5th ed., Fiebach DH, ed. LWW.
Ancillary Educational Materials
Subspecialty Texts of Neurology, Pulmonary Medicine, Nephrology, Endocrinology,
Infectious Diseases, Rheumatology as well as General Medical References (Harrison’s
Principles of Internal Medicine, Cecil’s Textbook of Medicine) are available 24 hours a day,
seven days a week in the resident lounge.
Savitt Medical Library On-Line
Residents have access to the on-line services of Savitt Library (the main library of the
University of Nevada - Reno) via their computer in the resident room, Suite 300 of the 2040
W. Charleston Building. Access to this room is available 24 hours a day, seven days a
week.
Full text is available for many peer-review journals including, but no limited to:
ACP Journal Club
Annals of Internal Medicine
British Medical Journal
Cancer
Circulation
Journal of the American College of Cardiology
The Lancet
New England Journal of Medicine
Stroke
Also available on-line:
Harrison’s Principle’s of Internal Medicine, 16th ed.
Merck Manual, 17th ed.
Guide to Clinical Preventive Services, 2nd ed.
The Cochrane Library
Medline and Grateful Med Databases
The Medical Letter
Training Sites
The ambulatory outpatient experience occurs at the Lied Ambulatory Clinic
and Total Life Care.
Competency-based Goals and Objectives
Ambulatory Block Rotation
(Only a single level of competency is described, as this is a resident-level rotation
undertaken once during residency, after internship)
Learning Venues
Evaluation Methods
1. Direct Patient Care
2. Directly Observed Procedures
3. Residency Core Lecture Series
4. Weekly Ambulatory Conference
5. Self Study
A. Attending Evaluation
B. Direct Observation
C. Nurse Evaluation
D. Written Examination
E. Self-evaluation
Competency: Patient Care
Obtain an accurate, logical, and
efficient history and physical
examination from the patient
and other sources of patient
information.
Independently generate
differential diagnosis,
diagnostic strategy, and define
appropriate therapeutic plan and
modifications to therapy in
patients
Make informed decisions and
recommendations about
preventive, diagnostic, and
therapeutic options and
interventions based upon
clinical judgment, scientific
evidence, and patient
preference.
Triage and appropriately
prioritize multiple problems.
Properly order and interpret
results of tests and procedures.
Demonstrate competency in
performing clinic procedures.
Consistently demonstrate
respectful and caring behaviors
with patients and their families
as well as with clinic healthcare
Learning Venues
1
Evaluation Methods
A, B, C,E
1, 2, 3, 4, 5
A, B, C, D, E
1, 2, 3, 4, 5
A, B, C, D, E
1
A, B, C,E
1
A, B,E
1, 2
A, B, C
1, 2
A, B, C
personnel.
Monitor and follow up on
patient issues during clinics and
between outpatient visits.
Demonstrate satisfactory
performance on mini-CEX
1
A, B, C
1, 2
A, B
Competency: Medical
Knowledge
Improve knowledge of the
broad range of common medical
problems in the ambulatory
setting
Improve knowledge of
preventative care, including
published guideliens
Acquire and critically evaluate
current medical information and
scientific evidence relevant to
ambulatory patient care.
Assess the validity of original
research concerning clinical
questions and present the
evidence in ambulatory
morning reports.
Appropriate chooses
medications with demonstration
of knowledge of different
options and adverse effects.
Applies knowledge to diagnosis
and therapy.
Demonstrates an investigatory
and analytic thinking approach
to clinical situations.
Understand and describe to the
patient pertinent procedures
done in the ambulatory setting
Know the appropriate
diagnostic tests and studies
ordered in the ambulatory
setting for health care
maintenance and preventative
medicine.
Learning Venues
Evaluation Methods
1, 2, 3, 4, 5
A, B, C, D, E
1, 2, 3, 4, 5
A, B, C, D, E
1, 2, 3, 4, 5
A, B, C, D, E
1, 2, 3, 4, 5
A, B, C, D
1, 2, 3, 4, 5
A, B, C, D
1, 2, 3, 4, 5
A, B, C, D, E
1, 2, 3, 4, 5
A, B, C, D, E
1, 2, 3, 4, 5
A, B, C
1, 2, 3, 4, 5
A, B, C, D, E
Competency: Interpersonal
and Communication Skills
Interact in an effective and
respectful way with patients and
medical support staff
participating in the care of
patients in the ambulatory
setting.
Maintain comprehensive,
accurate, and legible medical
records in a timely fashion.
Show understanding of
differing patient preferences in
evaluation and management of
medical conditions.
Serve as a patient advocate.
Provide education and
counseling to patients and their
families.
Create and sustain
therapeutically and ethically
appropriate relationships with
patients and families.
Compose well organized,
succinct, thorough notes.
Respect patient confidentiality.
Effectively communicate with
patient in urgent matters
between outpatient visits and
accurately dictate the encounter.
Learning Venues
Evaluation Methods
1, 2
A, B, C, E
1, 2
A, B, C, E
1, 2
A, B, C, E
1, 2
1, 2
A, B, C, E
A, B, C, E
1, 2
A, B, C, E
1, 2
A, B, C, E
1, 2
1
A, B, C, E
A, B, C, E
Competency: Professionalism
Treat team members and
patients with respect and
empathy
Understand, practice, and
adhere to a code of medical
ethics pertaining to the
provision of care, patient
confidentiality, informed
consent, and business practices.
Actively participates in all
clinics
Acknowledge errors to
minimize them
Learning Venues
1, 2
Evaluation Methods
A, B, C, E
1, 2
A, B, C, E
1, 2
A, B, C
1, 2
A, B, C, E
Attend and participate in all
scheduled conferences.
3, 4
Attendance, A
Competency: Practice-Based
Learning
Learning Venues
Evaluation Methods
Compares personal practice
patterns to larger populations
and analyzes personal patterns
systematically to improve.
Incorporate case studies with
relevant research outcomes and
report those findings during
clinical encounters.
Effectively applies evidence
based medicine to clinical care.
Review the outcomes of patient
care in order to reflect on the
approach taken in the delivery
of care
1, 2
A, E
1, 2, 4, 5
A, E
1, 2, 4, 5
A, E
1, 2
A, E
Utilize established practice
guidelines for individual
diseases to devise care
strategies
1, 2, 3, 4, 5
A, E
Identify limitations of one’s
medical knowledge and skills
and uses medical literature
(primary and reference) to
address these gaps in medical
knowledge
Facilitates the learning of
students, fellow residents, and
other health care professionals.
Undertakes self evaluation with
insight and initiative.
Effectively utilizes medical
records and information
databases as a means of
obtaining relevant materials to
enhance patient care.
Accepts feedback, develops and
implements self-improvement
plan.
1, 2, 4, 5
A, E
1, 2
A, E
1, 2, 4, 5
A, E
1, 2
A, B, C, E
1, 2
A, B, C, E
Competency: Systems-Based
Learning Venues
Evaluation Methods
Practice
Applies evidence-based and
cost-conscious strategies toward
disease prevention, diagnosis,
and management.
Understands referral process for
ambulatory patients, including
identifying patients requiring
hospitalization.
Participates in developing
methods to improve systems of
practice and health management
Uses systematic approaches to
reduce errors.
Collaborates with other
members of the health care
team to assist patients and
improve patient care.
Appropriately utilizes medical
and non-medical subspecialties.
Advocates for quality patient
care and assists patients in
dealing with health system.
1, 2, 4, 5
A, B, C
1, 2
A, B, C
1, 5
A, B, C, E
1, 2, 4, 5
A, B, C, E
1, 2
A, B, C, E
1, 2
A, B, C
1, 2
A, B, C, E
EVALUATION
A. Of Residents
At the completion of each rotation, all clinical faculty are required to complete the standard
ABIM resident evaluation form. All clinical faculty are encouraged to provide face-to-face
feedback with the residents. Residents may receive interim feedback utilizing the ABIM’s
Praise and Early Warning cards. In addition, faculty are required to perform “mini-CEX”
evaluations on the resident in the ambulatory setting.
B. Of Rotation and Preceptor
All residents are encouraged to evaluate the rotation, and the clinical faculty member, at the
completion of the rotation. This evaluation form is included at the end of this document.
These evaluations are then converted to type and shared anonymously with the clinical
faculty. Residents are also encouraged to give on-going feedback during the rotation to
ensure the experience is suiting their educational needs.
The program director also discusses the rotation with the residents to ensure rotation quality
and satisfaction.
Ambulatory Block Rotation Resident Check List
___________ 1.Evaluation reviewed at mid-rotation end of rotation by the supervising
faculty member and resident.
___________ 2. Completed assigned readings and assignments.
___________ 3. Attended all assigned clinical activities (excluding scheduled time
away, required clinics and emergencies).
___________ 4. Completed required presentations, case reports abstracts and/or posters
assigned by the supervising faculty member.
___________ 5. Demonstrated understanding of the basics principles of medical diagnosis and
management in the ambulatory setting.
___________ 6. Received verbal feedback from attending at end of rotation.
.
Intern/Resident Signature_________________________
Date___________________
Supervising attending__________________________
Date___________________
All items must be completed for rotation credit and checklist returned to the Department of
Medicine by the rotation’s end.