Yale Internal Medicine / Pediatrics Residency Training Program
Ambulatory Medicine
Developing the skills and expertise necessary for the practice of outpatient medicine is an essential component of residency training in both internal medicine and pediatrics. There is also growing recognition that essential aspects of office practice, such as doctor-patient-family communication, evidence-based decision-making, preventive medicine, and office-based procedures, should be taught to residents in training. An extensive ambulatory curriculum has been developed to meet these needs, and is learned in a variety of venues and rotations.
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Med-Peds housestaff have their continuity practices in a modern clinic built by St. Mary's Hospital in Waterbury specifically for this purpose. It is a combined clinic, caring for both adult and pediatric patients at all times. Resident practices are supervised by full-time Med-Peds faculty who are free from other scheduled responsibilities while precepting housestaff. Faculty also cares for their own patient panels, drawn from the same local population, in the same clinic during separate sessions. New patients, ranging from newborns to octogenarians, are recruited by faculty and housestaff from St. Mary's newborn nurseries, pediatric and adult in-patient wards, and from a growing panel of satisfied, ethnically diverse families. Referrals of Waterbury-dwelling patients are also received from the nursery and subspecialty services at Yale. The Faculty has developed clinical programs in HIV, Neonatal HIV, Hep C, Heroin Addiction and the care of chronically ill children. These clinical enterprises further expand our residents’ clinical training.
A pre-clinic conference series addresses topics in both specialties, drawing on educational materials developed by Yale and local faculty. A local chapter of the nationally acclaimed Reach Out and Read program helps med-peds providers promote literacy amongst their patients.
Essential primary care skills are also taught during outpatient block rotations and electives. Throughout the four years, acute ambulatory care is learned alongside pediatric housestaff at Yale's Primary Care Center, and through adult and pediatric ER rotations. Pediatric outpatient electives include time in subspecialty outpatient clinics. Rotations are provided in adolescent medicine, developmental pediatrics, and the private offices of community-based internists, pediatricians and Med-Peds practitioners. These latter experiences also provide exposure to the business and logistical aspects of practice management.
Ambulatory Medical Education
The didactic component of the ambulatory curriculum includes the pre-clinic conferences (see above), which provide practical, case-based reviews of common outpatient topics. During the ambulatory block, residents also participate in an Ambulatory Core Curriculum that includes a resident/faculty-taught evidence-based medicine series; workshops on physician-patient communication skills, and workshops on minor office procedures. Also included are seminars in preventive medicine, psychosocial medicine, women's health, preoperative consultation, and outpatient management of common chronic diseases. There is a weekly ambulatory morning report in medicine, and a weekly series of outpatient pediatrics conferences at both Waterbury and Yale, which housestaff attend (depending on location) when on outpatient rotations.
The ambulatory curriculum also emphasizes other areas of Internal Medicine and Pediatrics which are essential to a generalist-physician, such as Geriatrics, Occupational and Environmental Medicine, Addiction Medicine, Adolescent and Behavioral Medicine, and related specialties including Neurology, Psychiatry, Gynecology, Dermatology, Ophthalmology, and Orthopedics. Residents also have an opportunity to participate in community projects. Residents may rotate through a medical clinic established by Program faculty in a homeless shelter or participate in community health promotions and disease prevention projects. Residents may also contribute to an annual month-long basic science review/career counseling course for minority college students who will be applying to medical school that is sponsored by the Primary Care Residency Program and the Office of Multicultural Affairs.
There are several other educational activities of relevance to ambulatory medicine and pediatrics. Both the medicine and pediatrics departments enjoy a high-quality journal club. The Pediatrics department holds a quarterly ethics series. The Med/Peds Faculty conduct a monthly Medicine or Pediatric Board Review.
The Yale Office-based Medicine Curriculum and The Yale Curriculum in Primary Care Pediatrics
Residents learn to assess and manage common ambulatory problems by doing just that under the supervision and guidance of their faculty preceptors. To enhance this clinical experience and supplement any gaps in their firsthand encounters, however, we developed a literature-based curriculum that covers a wide span of primary care topics in internal medicine and pediatrics. The curriculum serves to provide an evidence-based approach for what we clinically practice and supplement practical experience with a didactic foundation, particularly in the case of unusual conditions a resident might encounter only rarely, and provide updates when new developments occur in therapy or standards of care.
The cornerstones of this curriculum are realistic challenging cases and related questions which emphasize practical aspects of diagnosis or management. These exercises prompt not only information recall but also higher order cognitive skills, such as solving problems, evaluating new information, and making judgments. Twice a year, each resident receives a six-month syllabus of cases with related questions, and one or more high quality, peer-reviewed articles. Topics are selected by faculty with resident input and range from "bread and butter" primary care areas such as diabetes, asthma, normal childhood development, and prevention to specialty areas, such as orthopedics, rheumatology, and dermatology. Each semester also includes chapters relevant to current practice, including such topics as coding, psychosocial medicine, or economic aspects of medicine, as well as recent therapeutic advances. Over four years of residency, residents will be exposed to a compendium of approximately 150 different topics as part of the rotating syllabus.
Both the internal medicine and pediatric aspects of the curriculum enjoy a high level of satisfaction based on annual surveys of residents and faculty. The Yale Office-based Medicine Curriculum was developed in 1992 and is currently used by more than 150 residents and 70 faculty in the Yale Primary Care, Traditional, and Combined Medicine-Pediatrics Residency Programs. As a testament to the high quality and unique features of the curriculum, approximately 50 medicine residency programs across the U.S. also use the Yale Office-based Medicine Curriculum as part of their ambulatory training. Recognizing that no such curriculum existed for pediatric training, Med/Peds faculty and residents spearheaded the development of The Yale Curriculum in Primary Care Pediatrics in 2005. It is currently used by more than 70 residents and 20 faculty in the Yale Pediatrics and Combined Medicine-Pediatrics Residency Programs.
In our program, The Yale Office-based Medicine Curriculum and The Yale Curriculum in Primary Care Pediatrics serve as the basis for the weekly pre-clinic conference that takes place in the half hour prior to residents seeing their patients in continuity clinic. This conference is led either by a faculty preceptor or a resident under faculty supervision. We expect the residents to read the cases and key reference materials prior to coming to a 30-minute conference. The groups are small (including only residents and faculty who have clinic that day), which facilitate active discussion and personalized education.
Read further information on the Yale Office-based Medicine Curriculum