Primary Care Residency Program
Ambulatory – Continuity Clinic
Categorical residents have their continuity clinic one half-day per week at Henry S. Chase Outpatient Center. They provide ongoing continuity care for their own panel of patients under the supervision of experienced, academic general internists, who hold full-time faculty appointments in the general medicine section of the department of medicine at Yale. The faculty preceptors participate in an ongoing faculty development program to refine their ambulatory teaching skills.1
During the residents' clinic session, the faculty devotes their time exclusively to precepting and maintains a 3 to 1 resident to faculty ratio. Typically, each resident will see 4-6 patients as interns, 5-7 as PGY-II's, and 6-8 as PGY-III's. An innovative faculty-resident schedule synchronization system ensures that residents work with the same primary preceptor each week, even as their clinic day moves to accommodate inpatient rotation conflicts and duty hours restrictions. With this high level of continuity, faculty can maintain quality of care and efficiency (since they know the patients well), provide more substantive evaluations (since they observe the resident over time), and precisely target their teaching (since greater continuity improves appreciation of residents learning needs). The patient visits include new patients, return visits and urgent care and include a broad range of internal medicine conditions.
Several policies ensure that residents participate in their patients' care during unscheduled clinic time, emergency room visits, and hospital admissions. And plans are underway to implement a disease management model in which residents can orchestrate their patients’ care within a multidisciplinary team of providers. The faculty convenes a 30-minute pre-clinic conference that follows the (see below).
Preceptors complete yearly evaluations of the residents and offer ongoing informal feedback and direct observations (mini-CEXs).2, 3. Residents have the opportunity to evaluate their preceptors teaching skills and the operations of the clinics.
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Henry S. Chase Outpatient Center
The Henry S. Chase Outpatient Center (HSCOC) is located at 140 Grandview Avenue, a medical office building on the Waterbury Hospital campus. This practice is efficiently managed by the Alliance Medical Group, which manages many other hospital-affiliated practices in the community. An electronic medical record allows for seamless documentation and sharing of patient information among providers. Resources include built in audio-video equipment in two examination room, proxy server connection to the Yale Medical Library, a warfarin anticoagulation clinic, a multidisciplinary diabetes disease management clinic, and facilities for dermatologic cryotherapy. The practice sees greater than 20,000 visits per year, providing care for a large portion of the medically underserved citizens of Waterbury. The payer mix includes 62% Medicaid, 14% Medicare, 12% uninsured (self-pay), and 12% commercial insurers.
The Yale Office-based Medicine Curriculum and Preclinic Conference
Residents learn to assess and manage common ambulatory problems by doing just that under the supervision of their faculty preceptors. To enhance this experience and supplement any gaps in their firsthand encounters, however, we developed a literature-based syllabus known as the Yale Office-based Medicine Curriculum.
The cornerstones of this curriculum are realistic challenging cases and related questions prepared by faculty, 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. Each resident receives a six-month syllabus covering 24 cases paired with related questions and one or more peer-reviewed articles. Topics are selected by faculty with resident input and range from "bread and butter" internal medicine (such as diabetes, hypertension, 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. Each volume also includes recent therapeutic advances. Over three years of residency, residents will be exposed to a compendium of 144 different topics as part of the rotating syllabus.
The curriculum enjoys a high level of satisfaction among the 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.
In our program, the Yale Office-based Medicine Curriculum serves 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 small group setting facilitates active discussion and personalized education.
1Green ML, Gross CP, Kernan WN, Wong JG, Holmboe ES. Integrating teaching skills and clinical content in a faculty development workshop. J Gen Intern Med. 2003;18(6):468-474.
2Holmboe ES, Fiebach NH, Galaty LA, Huot S. Effectiveness of a focused educational intervention on resident evaluations from faculty a randomized controlled trial.[see comment]. J Gen Intern Med. 2001;16(7):427-434.
3Holmboe ES, Huot S, Chung J, Norcini J, Hawkins RE. Construct validity of the miniclinical evaluation exercise (miniCEX). Acad Med. 2003;78(8):826-830.