Primary Care Residency Program
Integrated Ambulatory Core Curricula
The didactic portion of the ambulatory core curricula consists of 24 seminars (or seminar series) on Friday mornings over the 12-week ambulatory block. As described below, the knowledge, skills, and attitudes learned in these seminars are reinforced in the clinical experiences in the ambulatory block, continuity clinic, and inpatient rotations.
Evidence-Based Medicine
To practice evidence-based medicine, a physician 1) Asks answerable questions when facing an information need, 2) Acquires the best evidence, 3) Appraises the evidence for its validity and usefulness, and Applies the evidence in patient counseling and decision-making. In Applying the evidence, he or she uses clinical expertise to integrate evidence with the particular clinical circumstances and the patient’s preferences. Our interactive EBM curriculum guides the residents through this process using the actual clinical questions arising in their patient care activities. The presenting residents also meet one on one with expert faculty, who have advanced training in EBM and have completed our own faculty development course. We also demonstrated the effectiveness our curriculum in improving residents EBM skills in a controlled trial.1 More recently, we have tried to integrate EBM into all of the program clinical venues by documenting residents medical information needs,2 elucidating the barriers to answering clinical questions,3 and capturing fertile EBM moments with a clinical question educational prescription.4
Quality Improvement
The ability to evaluate one's own practice and to make improvements is essential for professional growth and effective care. To this end, the ACGME has created a new general competency: practiced-based learning and improvement. We developed a targeted experience in quality of care and reflective practice. Each resident on the ambulatory block rotation participates in a multifaceted program (including reading, a record audit, and “academic detailing” with a faculty preceptor) designed to improve their knowledge of core principles and skills in quality of care. For the record audit, each resident analyses his or own practice performance in the areas of diabetes and prevention. This experience allows them to "reflect" on their own practice patterns and to make adjustments to improve the care the deliver to patients. A commitment to change strategy is also incorporated into the experience to re-enforce the personal goals each resident identifies at the end of the rotation. In a controlled trial, patients cared for by residents “exposed” to this curriculum received higher quality of care and enjoyed improved outcomes.5
Biostatistics
The residents participate in a 4-session biostastics curriculum, which emphasizes the proper interpretation of statistical test results found in the medical literature.6, 7 They also use this time to plan a statistical analysis for the own research proposals.
Chronic disease management (diabetes clinic)
PGY-2 residents participate in the Diabetes Disease Management Clinic8 on Wednesday mornings during their ambulatory block rotation. Patients of the resident and faculty practice with poorly controlled diabetes are referred to this clinic for a multidisciplinary intervention designed to comprehensively address their diabetes management and complications. Residents work with a faculty preceptor, an APRN case manager, a nutritionist, and social workers. At the start of each session, the residents and faculty discuss selected readings in 5 content areas: the chronic disease management model and addressing barriers to chronic disease care, microvascular complications of diabetes, macrovascular complications of diabetes, oral hypoglycemic agents, and use of different insulin preparations. Each reading is accompanied by cases that require application of information in the weekly readings.
Psychosocial Medicine
Studies estimate that 35% of patients in primary care practice have psychosocial, not biomedical, problems. Clearly, then, physicians must be grounded in the psychosocial, as well as the biomedical domains, in order to provide optimum care for their patients. The psychosocial domain encompasses 1) a patient-centered, as opposed to purely physician-centered, approach; 2) interviewing skills, including listening, empathy and an awareness of how one's own feelings, biases, responses, etc., affect the doctor-patient relationship; 3) a belief that all illnesses have psychosocial aspects that influence their cause, manifestation, course, and outcome; and 4) the skills to diagnose and treat common psychosocial problems, such as mood and anxiety disorders, somatoform disorders, substance abuse, domestic violence, and non-adherence. The psychosocial domain is complementary to the knowledge, skills, and attitudes of the biomedical domain. Incorporating both domains in clinical practice is the called the biopsychosocial approach, useful not only for patients with mental health problems, but for all patients.
Research shows that physicians who use a biopsychosocial approach to patient care have more satisfied and adherent patients, affect better health outcomes, are more professionally satisfied, and even have fewer malpractice suits! The Psychosocial Curriculum seeks to provide house staff with the knowledge, skills, and attitudes needed to be successful and fulfilled internists. This three-year curriculum includes didactic and experiential components led by internists, psychiatrists and psychologists. The didactic lectures in the ambulatory core curriculum are in the following areas: depressive disorders, anxiety disorders, somatization, post-traumatic stress disorder, obsessive-compulsive disorder, neuropsychiatry, psychosis, movement disorders, psychopharmacology, psychiatric epidemiology, organic brain disease, domestic violence, alcohol abuse, helping patients to change behaviors, dealing with difficult situations, primary care of gay and lesbian patients, helping patients improve adherence and spirituality in medicine.
Experiential components in the ambulatory block rotation include 1) primary care psychiatry consultation clinic, 2) outpatient substance abuse center, 3) medical interviewing tutorials,9 4) behavioral change counseling consultation clinic, and 5) difficult patient workshop.
Women’s’ Health
Historically, women's health issues have been under-represented in residency training. Recognition of this fact has led the American Board of Internal Medicine, American College of Physicians, National Academy on Women's Health Medical Education and the Federated Council for Internal Medicine to define core competencies in this area. In addition, our program developed a written curriculum comprised of 35 core topics in Women's Health, which includes a list of educational goals and an up-to-date bibliography. Our curriculum attempts to meet the goals through an integrated curriculum:
- A lecture series with the ambulatory core curriculum entitled “women’s health across the lifespan”
- Clinical community rotations10 on the PGY-2 ambulatory block rotation, including the Yale Women’s Center, Planned Parenthood, and city health departments.
- “Core cases” in women's health included in the pre-clinic conferences
- A section on “medical complications during pregnancy” in the medical consultation curriculum
- A tutorial on performing PAP smears and pelvic exams with educator-models
Out program also tries to respond to the special concerns and interests of our women residents. To this end, two faculty organize regular after-hours “Women in Medicine” potluck dinners where a guest of honor shares her experiences in medicine.
Preventive Medicine
Expert faculty give interactive lectures on various aspects of cancer screening, immunization, chemoprophylaxis, nutrition, and obesity.
Clinical Updates
As part of the ambulatory core curriculum series, faculty discuss new clinical developments in rapidly evolving areas of outpatient medicine, including HIV infection, Hypertension, and Diabetes Mellitus. Other seminars include telephone and a hands-on workshop on dermatologic procedures (practicing on pigs’ feet).
1Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med. 1997;12(12):742-750.
2Green ML, Ciampi MA, Ellis PJ. Residents' medical information needs in clinic: are they being met? Am J Med. 2000;109(3):218-223.
3Green ML, Ruff TR. Why Do Residents Fail to Answer Their Clinical Questions? A Qualitative Study of Barriers to Practicing Evidence-Based Medicine. Acad Med. 2005;80(2):176-182.
4Green ML. Evaluating evidence-based practice performance (editorial). ACP Journal Club. Sep-Oct 2006;145:A8-A10.
5Holmboe ES, Prince L, Green ML. Teaching and Improving Quality of Care in a Primary Care Internal Medicine Residency Clinic. Acad Med. 2005;80(6):571-577.
6Windish DM, Huot SJ, Green ML. Medicine Residents' Understanding of the Biostatistics and Results in the Medical Literature. Vol 298; 2007:1010-1022.
7Windish DM, Diener-West M. A clinician-educator's roadmap to choosing and interpreting statistical tests. J Gen Intern Med. Jun 2006;21(6):656-660.
8Kansagara DL, Holmboe ES, Carr K, Huot SJ. Establishing a diabetes disease managment program in a resident clinic (Abstract). J Gen Intern Med. 2005;20 (Suppl 1):31.
9Fortin AH, Haeseler FD, Angoff N, et al. Teaching pre-clinical medical students an integrated approach to medical interviewing: half-day workshops using actors. J Gen Intern Med. 2002;17(9):704-708.
10Brienza RS, Whitman L, Ladouceur L, Green ML. Evaluation of a Women's Safe Shelter Experience to Teach Internal Medicine Residents About Intimate Partner Violence. A Randomized Controlled Trial. J Gen Intern Med. 2005;20(6):536-540.