PGY-1 Ambulatory Medicine

2017-2018

Overview:

The Ambulatory Medicine Rotation is designed to enhance your practice of ambulatory medicine.  The Ambulatory Rotation has a rich and dynamic curriculum encompassing a wide range of arenas that are all critical to ambulatory care, including biomedical, behavioral, social, and epidemiologic elements and that will be build upon each year. There is also significant time spent in the clinic, actively using your knowledge and skills to diagnose and manage diseases in the outpatient setting, and learning to do all this in the psychological and social context of the individual patient.

Goals:         

The out-patient medical service experience is designed to enhance the practice of ambulatory medicine.  In addition to the interactive didactic curriculum, you will spend significant time in clinic, managing your continuity patient panel. Under supervision, the house officer is expected to actively use their knowledge and skills to diagnose and manage diseases in the outpatient setting, and learning to do all this in the psychological and social context of the individual patient. The patients in the outpatient service are ethnically and socioeconomically diverse and provide a great variety of acute and chronic conditions. The house officer is expected to develop the ability to interact effectively with patients and interdisciplinary team members. Over the course of the 3 years, the house officer will become familiar with specific disease entities encountered in the internal medicine practice. We expect that this familiarity will be augmented by specific subspecialty and elective rotations.

Under the "6+2" system, you will have an ambulatory block every six weeks. For any time that the resident does not have a scheduled clinical session for more than 4 weeks, additional clinical sessions will be scheduled during that time frame. 


Objectives:

 -          Patient Care: To manage patients’ medical conditions under direct supervision, begin to recognize the relative significance of a given patient's list of medical conditions; begin to recognize the acuity levels of illness; inquire about the indications, contraindications and risks of common procedures; work with all providers to provide patient-focused care

-          Medical Knowledge:  Use literature and reference sources to increase knowledge base; demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of basic disease states; apply knowledge in the treatment of patients 

-          Professionalism:  Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff; work to fulfill the needs of patients; accept assignments graciously; attend conferences; complete assigned tasks.

-          Interpersonal and Communication Skills: Write understandable and timely notes; effectively communicate with patients (verbally and nonvervally) in order to facilitate their medical care; work effectively as a member of the health care team.

 -          Practice Based Learning and Improvement:  Recognize limitation of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed.

 -          Systems Based Practice:  Advocate for patients; learn about the health care system/structure and begin to develop mechanisms to utilize ancillary services to benefit patients

Expectations:

-          Clinic notes - complete history, physical examination, diagnostic assessment, and therapeutic plans within 2 days of clinical encounter

-          Enter appropriate orders - therapy, tests, records, consents, procedures and consults

-          Participate in all didactic and educational seminars

-          Participate in discussions with patients and families

-          Complete appropriate paper forms pertinent for patient care in a timely manner

-          Communicate with other providers if pertains to medical care of your patients

    Inbox Management per Policy (listed under Clinic Site)


 

The Ambulatory Rotation for the PGY-1 year includes:

  • Clinic
  • Didactic Ambulatory Curriculum (Topic Talks)
  • Psychosocial Curriculum (OSCEs, Home Visits)
  • Ambulatory Morning Report (AMR)
  • Chief Resident Rounds (CR)
  • Evidence-Based Medicine Seminar: Journal Club (JC) and Epidemiology Didactics
  • Night Medicine Floor Coverage – Northwest or Weiler
  • Administrative Time
  • Hopkins Modules (optional)

 

Please carefully note your schedule online at www.montemedicine.com for dates, times, locations, and other details regarding the various Ambulatory rotation components.  Also, please note that many sessions involve prior preparation, the materials and details of which are posted on the website.

  

Clinic

Clinic is the heart of the rotation--it is a fun and rewarding place to create longitudinal relationships with your patients.  As a patient's primary care doctor, you will be the centerpiece of integrating their medical care in a patient-centered way.  Like any new service, clinic can be a bit confusing at first. Though this can be challenging, the material learned during clinic and outpatient work-flow are crucial to medical practice. During each clinic session, there are preceptors who are not seeing patients, but are specifically there for precepting.  All cases must be discussed with an attending, and the charts cosigned.  For the first half of intern year, the attending will see the patient briefly with you after precepting.  The FCC and CFCC clinics have many excellent clinician-teachers.  They will also help you navigate the electronic medical record system and clinic.

When you see “walk-in” or “cross-coverage” patients, ask the patient who their primary doctor is. If the doctor is no longer at Montefiore, or if the assigned doctor is a newly assigned intern/resident who the patient has not yet seen, then that patient should become your patient.

Speak to the preceptor about reassigning the patient to your panel.  (It may simply mean changing the name in the computer.)

 

Topic Talks

Many didactic sessions are included in the curriculum.  They focus on important topics in ambulatory medicine. The topics that are covered are listed on the right. 

 

Psychosocial Medicine

The goals of the curriculum are to improve our ability to communicate with patients and to expand our knowledge-base of topics in psychosocial medicine.  Topics to be covered during Ambulatory Rotation include: anxiety, depression, somatization, cultural competence, sexual history, and delivering bad news.    

OSCEs are one of the main learning venues for psychosocial medicine.  These will be discussed individually, prior to the sessions.

 

 Ambulatory Morning Report (AMR)

AMR is an opportunity for you to review patient care and management, to discuss issues related to your patients, and to learn from each other.  Patients selected for AMR do not need to be "complicated" or "zebra" cases--we have something to learn from all of our patients, so you can choose the last patient you saw in clinic.  The sheet has an OPTIONAL question portion; please note, your specific question may not be addressed during this session.

The Clinical Encounter Forms (CEFs) are the basis for this conference.  You will complete one CEF for the AMR session.  Look on the calendar to see when the CEFs are due. When you complete it, email the CEF to the faculty member leading AMR, which you can find on the calendar as well.  Please email the CEF to the relevant faculty member and the ambulatory chief resident on the assigned date by 6p (at the latest).  The faculty member reviews the sheets and identifies issues to be discussed.  CEF completion, complicated or uncomplicated, is essential to the success of the month.

 

 Chief Resident Rounds

The purpose of the chief resident rounds (CR) is to provide an opportunity to teach each other about issues relevant to your own patients.  Throughout the course of the year, each intern will make 1-2 presentations (about 20-30 minutes) on any ambulatory medicine topic of her/his choosing, but should be focused on answering a specific question about one of your clinic patients.  Topics should be discussed with Jamie Mersten at least THREE DAYS prior to the session. 

The presentations should begin with a brief synopsis about the patient leading into the clinical question to be addressed and woven throughout with a 30 minute presentation on the topic, then a wrap-up applying what you learned towards your particular patient.  Time is short; clear focus is essential.  The topic can be researched in ambulatory medicine texts and/or the literature and should have prior approval from the Chief Resident.  

 

Evidence Based Medicine

Evidence-based medicine (EBM) is an integral part of the practice of medicine for any physician.

You will receive lectures on different topics covering key components of Epidemiology in order to improve your skill set in understanding the literature and creating your own clinical questions.

In the Journal Clubs seminars, each intern will discuss a major journal article, which has been assigned from the list of papers on the Monte medicine website.  The articles for selection are under the literature tab-à Journal Club àAmbulatory journal club Fall 2014. 

Everyone is expected to read the article for journal club and come prepared to discuss during the session.  Relevant information on statistics and EBM will be reviewed at these sessions.

 

Night Medicine Coverage

During the weekends, you may be scheduled to cover night medicine floors on Saturday and Sunday nights at either Moses or Weiler campuses. Please see your schedule on New Innovations to see if/when/where you are covering. If you are scheduled for Moses, please arrive at the NW5 conference room at 8:00 pm to obtain your team assignment for the weekend. If you are scheduled for Weiler, please arrive at the 2nd Floor Medicine Office conference room at 8:00pm to obtain your team assignment for the weekend.  Your shift will end after attending rounds with your teams the following morning at 10:00am.

Administrative Time

The purpose of Administrative Time is to provide you with an opportunity to contact patients, complete your notes and forms, or take care of any patient related material.

 




Reminders!
  1. Check your email daily
  2. Carry your pager with you
  3. Log your work hours
  4. Complete the forms in your inbox
  5. Check your Epic inbox daily even if you are not on Ambulatory rotation.
  6. Attend Ground Rounds 
  7. Complete your EMR clinic notes within two days of visit. 


 

Lecture Locations

SCHIFF B CONFERENCE ROOM:  In FCC, take the stairs (or elevator) to the 2nd Floor.  Walk straight from the elevator up a small ramp and into the hallway.  At the end of the hallway, make a right.  Walk to the end of this hallway.  Schiff B is the last door on the Right.  Code for Door is 2351

WEILER MEDICINE CONFERENCE ROOM:  2nd floor Weiler in the Medicine Department Suite

WEILER OB/GYN CONFERENCE ROOM:  2nd floor Weiler, across from the staff/service elevators

CFCC MEZZANINE CONFERENCE ROOM:  Enter CFCC from 1515 Blondell entrance (Med Park stop on the shuttle).  Walk up the stairs to the first landing (not the second floor).  Enter the door at this level.  After entering the hallway, make a right and proceed to the conference room in front of you.

CFCC LIBRARY CONFERENCE ROOM:  Enter CFCC from 1515 Blondell Ave (Med Park stop on the shuttle).  Walk up the stairs to the 2nd floor.  Enter the Adult Medicine Practice.  At the front desk, make a right and enter the double doors to get into clinic.  Once inside clinic, make your first left.  At the end of this hallway, make a right and proceed to conference room at the end of the hallway.


Questions

Jamie Mersten, MD

Chief Resident, Ambulatory Medicine

718-920-4360 (office)

jmersten@montefiore.org

We welcome your feedback and suggestions about the various components of your Ambulatory rotation.  We are committed to making changes that are needed to improve your educational experience during the rotation.

 




Ambulatory Core Curriculum
Ambulatory Morning Report (AMR)
Clinical Encounter Form
Clinical Encounter Form (word document)

Journal Club
 (JC)
Therapy Critique Sheet
Diagnostic Test Critique Sheet
Prognosis Critique Sheet

July/August:  Diabetes
DPP
DPP Intervention (Optional)

ACCORD

Sept/Oct:  Hypertension
ALLHAT
HYVET

Nov/Dec:  Obstructive Airway Disease + CAD
SMART
POET , POET supplement (optional)
COURAGE

Jan/Feb:  HTN (update!) +  DM (update!)
SPRINT
Leader

Mar/April: 
HIV
START 
IPrEx

May/June: COPD
Uplift
Torch

Epidemiology:

Evidence-Based Physical Diagnosis rounds (Abdominal Exam),  presented by Dr. Jamie Mersten
Forming a Clinical Question, presented by Dr. Sree Raghavan
Searching the Medical Literature, presented by Dr. Michael Bogaisky
Library Resources, presented by Marie Elias

High Value Care Sessions:
HVC #1,  presented by Dr. Gloria Fung Chaw
Overkill New Yorker article (pg 13 to end)
Case
Questions (please complete prior to session--email or print answers)
HVC #1 Journal Club, presented by Dr. Gloria Fung Chaw
HVC #2, presented by Dr. Nori Murakami
HVC 2 Reading

Reasoning Without Resources, presented by Global Health fellows/faculty

RWR#1, presented by Dr. Gloria Fung-Chaw, Dr. Morgen Yao-Cohen, and Dr. Amit Patel
RWR Case Series 1

RWR#2, presented by 
Dr. Gloria Fung-Chaw, Dr. Morgen Yao-Cohen, and Dr. Amit Patel
RWR Case Series 2


Topic Talks:
Abnormal Liver Tests,  presented by Dr. Maria Duda

Acupuncture,
presented by Dr. Ginger Wey

Advanced Directives
, presented by Dr. Carol Kelly
A Model for assessment of patient preferences 
Beyond Advanced Directives
Advanced Care Planning: Beyond the Living Will  Developing a Policy for DNR

Alcohol and Drug Abuse Screening
, presented by Dr. Aaron Fox    
Unhealthy Alcohol Use 
Helping Patients Who Drink Too Much

Alcohol Screening, presented by  Dr. Melissa Stein
1. Review the NIAAA Clinician's Guide in advance of the session
2. Review the four video cases available at the NIAAA website at the following links. These can take up to 40 minutes to review, so plan ahead.
3. Please print out and bring in the Audit-C
Anemia,  presented by Dr. Linda Wang
Interpretation of Hemoglobin Electrophoresis

Anticoagulation, presented by Dr. Elizabeth Harris

Asthma, presented by Dr. Jamie Mersen
Assist Devices,  presented by Dr. Mat Kladney
Breast Mass, presented by Dr. Rosemarie Conigliaro

Cancer Screening, presented by Dr. Darlene Lefrancois

Cancer Screening in Special Populations, presented by Dr. Claiborne Childs
Cardiac Exam, presenting by Dr. Jamie Mersten
Care of LGBT patients, presented by Dr. Viraj Patel, Dr. Robert Beil, and Dr. Brianna Norton  
Creating a Practice that is Open to LGBT Patients (ACP)
Chronic Cough, presented by Dr. Dicpinigaitis

Chronic Kidney Disease, presented by Dr. Carolyn Bauer

Cocaine/Marijuana,  presented by Dr. Melissa Stein

Common Dermatologic Illness, presented by Dr. Glennis Rodriguez

Common Thyroid Illnesses, presented by Dr. Lolita Sayseng

Contraception, 
presented by Dr. Jessica Atrio

COPD, presented by Dr. Daniel Fein

Cytopenias, presented by Adam Binder
Dementia, presented by Dr. Rubina Malik

Diabetes #1, presented by Dr. Jamie Mersten
Diabetes Treatments (#2), presented by Dr. Rita Louard

Diabetes Standard of Care (#3), presented by Dr. Rita Louard
Dizziness, presented by Dr. Rosemarie Conigliaro

Dyspepsia, presented by Dr. Shwetha Iyer

Eye Exam, presented by TBD
Eye Exam: Basics
Eye Powerpoint

Falls, presented by Dr. Alice Guo
Geriatrics in the Community, presented by Dr. Amy Ehrlich

HIV Screening & Prevention,  presented by Dr. Peter Alpert

Hyperlipidemia, presented by Dr. Darlene Lefrancois

Hypertension, presented by Dr. Tina Chae
Immunizations, presented by Dr. Ginger Wey and Dr. Jamie Osman
Immunizations Lecture Slides


Intimate Partner Violence, 
 presented by Dr. Debbie Swiderski
USPTF screening guidelines
Basic Reading:  Please focus on McCauley & Eberhard-Gran articles

Intro to Allergy, presented by Dr. Manish Ramesh 

Intro to Outpatient Infectious Disease, presented by Dr. Priya Nori

Intro to Infectious Disease Lecture Slides
Judicious Prescribing of Antibiotics
URI Treatment
Outpatient Antibiotics
Pneumococcal Vaccines

Intro to Substance Abuse, 
presented by Dr. Melissa Stein

Introduction to Teaching, presented by Dr. Darlene LeFrancois
Powerpoint

Medicine in the Bronx,
presented by Julissa Adames-Torres

Migraine, presented by Dr. Jelena Pavlovic

Nutrition, presented by Laura Grabisch

Obesity/Motivational Interviewing, presented by Dr. Sheira Schlair
Cases - See Email
Articles:
Li
Maggard
Puziferri
Fischer
Serdula
Yanovski

Additional Articles:
Motivational Interviewing
 by Treasure
Motivational Interviewing by Kausman
Obstructive Sleep Apnea, presented by Dr. Jamie Mersten

PREP-OSA Review Chest 2008
(Optional) JAMA RCE OSA


Pain Management/Chronic Opioids,
presented by Dr. Joanna Starrels
Powerpoint presentation
Project Grow, presented by Dr. Melissa Stein

SSRIs-An introduction for Primary Care Practice, presented by Dr. Jack Castro

Sexual Transmitted Infections, presented by Dr. Lauren Shapiro

Smoking Cessation, presented by Dr. S Nahvi

Treatment of Opioid Dependence , presented by Dr. Melissa Stein

Tuberculosis and PPDs, presented by Dr. Serena Roth

Behavioral Medicine OSCE:
Empathy
Breaking Bad News
End of Life Care
Treatment of Anxiety & Depression
In the Clinic: Depression
The Medical Interview: Sexual History
NEJM: Panic Disorder
Generalized Anxiety Disorder
Treating the patient with medically unexplained symptoms
The Medical Interview: The bilingual interview & Medical Interpretation
Cross-Cultural Communication
11 tips to Work with Medical Interpreter

Home Visits,  with Dr. Lauren Shapiro, Dr. Serena Roth, Dr. Sharon Leung, Dr. Maria Duda, Dr. Reena Agarwal


Medical Directors' Curriculum:
Epic 101, presented by Drs. Ginger Wey, Elizabeth Harris, Maria Duda, and Gianni Carrozzi

Panel Verification and Management, presented by Drs. Ginger Wey, Elizabeth Harris, Maria Duda, and Gianni Carrozzi
Telephone Management with Dr. Ginger Wey