PGYII Ambulatory Rotation

Goals:         

The Ambulatory Rotation at the resident level is designed to refine your practice of ambulatory medicine and build upon your first year.  

The outpatient 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.

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 nonverbally) 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

 

Your Ambulatory blocks will be separated into two components: Ambulatory Curricular Blocks and Ambulatory Non-Curricular Blocks. In each component, you will have continuity clinic. However, you will receive didactic sessions and DM clinic during your Curricular block. During your Non-Curricular Block, you will participate in the Medical Directors' Curriculum on Thursday mornings.  

PGYII Non-Curricular Blocks:                                                                   

Block 1: Sept/Oct 

Block 2: Jan/Feb   

Block 3: May/June

PGYII Curricular Blocks:                                                                         

Block 1: July/August 

Block 2: November/December   

Block 3: March/April

Please carefully note the online schedules on the housestaff website (www.montemedicine.com) and New Innovations (www.new-innov.com) for dates, times, locations, and other details regarding the various Ambulatory components.  Also, please note that most sessions involve prior preparation. You can find the pre-readings and resources on the housestaff website under the “Curriculum” tab in Ambulatory - Residents. Any night floor weekend coverage shifts that you may be assigned to can be found on New Innovations as well.

Clinic

Clinic is the heart of the rotation. Your clinical experience will include your continuity clinic, non-IM specialty clinic, and diabetes care. Please note that you are expected to be at your clinical site at 8:45am.  All of the clinic schedules can be found in New Innovations on your daily assignments page.

 Diabetes Clinic

For your Diabetes Clinic, you will go on Mondays to Sweethearts (FCC) or Diabetes (CFCC) during your Curricular blocks. For FCC residents, you will meet with Dr. Pan at 1pm prior to Sweethearts clinic.

Discharge Clinic

For residents at CFCC, you will staff a Discharge Clinic on Tuesday mornings on your NonCurricular blocks.  This clinic session will focus on safe transitions of care from the hospital to the ambulatory care setting.  Dr. Harris will run this clinic with you

Pain Clinic

For residents at FCC, you will staff a Pain Clinic on Friday mornings on your NonCurricular blocks.  This clinic session will focus on the care of patients with chronic pain.  Dr. Roth will run this clinic with you

Topic Talks

Many didactic and interactive discussion sessions are included in the curriculum.  They focus on important topics in ambulatory medicine and Women’s Health. Most have pre-assigned reading and questions to help give you a knowledge base prior to the lecture. Please be alert and complete the readings before each session. The lecture schedule as well as the associated readings can be found on www.montemedicine.com, under “Curriculum” in “Ambulatory-Residents.”

Psychosocial Medicine

OSCE

There is an Observed Standardized Clinical Encounter (OSCE) which explores the psychosocial aspects to patient care.  

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.

 Clinical Epidemiology Curriculum

This makes up the back bone of the discussion based sessions designed to give you a sound foundation in clinical epidemiology. Over the two years in resident Ambulatory Medicine, you will gain a mastery of not just the guidelines but how to read the literature and make important decisions about the patient in front of you with a continuous curriculum.

You will, as part of this curriculum, be asked to complete reading and homework associated with each session.  Please note that these are to be completed independently. 

Journal Club 

 In the Journal Clubs seminars, each resident will do a literature search and select a journal article that answers a clinical question pertaining to their patient.  Please notify me 4 days prior to your journal club with your clinical question and the name of the article for approval.  Once approved, you must complete the critique sheet and email out article to your co-residents and co-facilitator 2 days prior to session. 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.

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 Brian Dorsey 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.

Please note, the AMR form as been updated: Clinical Encounter Form


Teaching Development: Resident Facilitated AMRs 

In order to practice teaching in different settings, the curriculum will include resident-led AMRs.  This will be a venue to practice teaching skills in a small group, interactive setting.  The AMRs will be collected by the chief approximately 1 week prior to your session, and will be distributed evenly before the co-presenters.  You can choose to utilize any type of teaching modality for these session, so they will serve as a great venue to practice your individual teaching style.

Quality Improvement / Medical Directors' Curriculum 

During your Non-Curricular Blocks, residents will participate in a medical directors' curriculum on Thursday mornings.  These workshops will be held at CFCC for all residents (including FCC).  During these workshops, residents will build and verify their continuity panel.  Using this panel, residents will design an intervention to achieve a Diabetes management goal.  Over the course of the year, residents will have the ability to monitor the progress of patients on their panel, and then develop a new intervention as needed.  Additionally, the workshops offered at the end of the year will focus on transitioning high risk patients to new providers.  

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 materials. 


Hopkins Modules

During your Curricular blocks, we suggest that you complete assigned Hopkins modules which are listed on right.

 

Reminders

1.      Carry your pagers.

2.      Check your email daily.

3.      Check your Epic inbox daily even when you are not on your Ambulatory rotation. 

4.      Complete your clinic notes within two days of visit. 

5.      Log your duty hours on New Innovations.

 

Questions?

Please feel free to contact me with any questions or concerns about the lectures or clinics. I also welcome your feedback and suggestions about the various components of Ambulatory Rotation.  We are committed to making changes that are needed to improve your educational experience during the rotation.

Brian Dorsey, MD
Chief Resident, Ambulatory Medicine



PGYII Ambulatory Curriculum 

            


Topic Talks:
Approach to Joint Pain,  presented by Dr. Clement Tagoe

Considerations at the End of Life, presented by Dr. Carol Kelly

Healthcare Financing/CARES, presented by Debbie Greenberg

Health Systems, presented by Dr. Reynolds
OPTIONAL review:  powerpoint presentation

Hepatitis C, presented by Dr. Brianna Norton
 
Hypercalcemia,  presented by Dr. Eric Epstein

Medications in an Older Adult, presented by Dr. Michael Bogaisky 

Preoperative Evaluation,  presented by Dr. Regina Lee

Travel Medicine,  presented by Dr. James Burst

Urinary Incontinence, presented by Dr. Rosemarie Conigliaro
Urinary Incontinence Handout


Epidemiology:
Diagnosis, presented by Dr. Jonathon Ross
 
Non-inferiority Studies, presented by Dr. Darlene LeFrancois

Principles of Screening, presented by Dr. Darlene LeFrancois
"Early Diagnosis", please read prior to session.
Questions, Part 1 and Cases, Part 2,  complete prior to session.

Therapy 1: Randomized Controlled Trials, presented by Dr. Sree Raghavan
Consort RCT (just for reference, can skim)

Therapy 2: Meta-Analysis, presented by Dr. Olga Aroniadis
 


Health Disparities:
Concrete Services Session/Health Disparities Practice Session,  presented by Dr. Lauren Shapiro and Dr. Iman Hassan
Cases (PREP)-please use the website to find community resources for these patient scenarios. These resources are listed under the "Clinic" tab divided by continuity clinic site.

Intro to Health Disparities, presented by Dr. Linda Wang and Dr. Iman Hassan
1. Braveman P. What Are Health Disparities and Health Equity? We Need to Be Clear. Public Health Reports. 2014;129(Suppl 2):5-8.
2. Healthy People 20/20 social determinants of health http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health , overview, understanding social determinants of health 


Immigrant Health / Legal Services,  presented by Mrs. Sylvia Miller

Incarceration and Medical Care, presented by Dr. Jennifer Stella
Required Readings:
Optional Readings:

Health Disparities Journal Club, presented by Dr. Linda Wang and Iman Hassan
 

Psychosocial: 
Bioethics curriculum, presented by Dr. Hannah Lipman

Mental Health Management Rounds, presented by Dr. Jing-Yu Pan
 
Psychosocial OSCE, facilitated by Dr. Sheira Schlair


Womens Health Series Seminars:
Preconception Planning, presented by Dr. Ellen Harrison
Diagnosis to Discuss, Please prepare one topic of this list for discussion
Please be able to describe preconception care for well women, and specific instructions for the topic you chose above
 
Medical Care in Pregnancy, presented by Dr. Ellen Harrison
 
Amenorrhea, presented by Dr. Darlene LeFrancois
 
Menopause, presented by Dr. Kimberly Cartmill
  

Quality Improvement:
Resident Practice Improvement Meetings, 
- Medical Directors' Curriculum with  Dr. Maria Duda and Dr. Elizabeth Harris (CFCC); Dr. Gianni Carrozzi and Dr. Ginger Wey (FCC)

Panel Management with Dr. Brian Dorsey


Workshops: 
Teaching Tools, presented by Dr. Danit Arad

Musculoskeletal, presented by Dr. Claiborne Childs


High Value Care: 
High Value Care #3,  presented by Dr. Amit Patel

High Value Care #3 Journal Club,  presented by Dr. Amit Patel

HVC/Gen Med Journal Clubs,  presented by Global Health fellows and faculty

High Value Care #4 Journal Club,  presented by Dr. Amit Patel

Sweethearts/Sweet Beats Clinic:
 
Hopkins Modules: 
Block 2 (July/August): Hip/Knee Pain and Menopause/HRT
Block 4 (Nov/Dec): Gynecology and Preoperative Evaluation
Block 5 (Mar/Apr): Immunizations Parts 1 & 2


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