In order to meet the individual interests and career goals of our residents, we offer three unique continuity clinic settings. These include the Adult Primary Care Center located at the St. Raphael’s Campus of YNHH (the main practice site for the Yale Primary Care core faculty); the VA Healthcare Center of Excellence in Primary Care Education; and The Nathan Smith clinic, which serves as the primary site for our HIV primary care training track. Each of these sites incorporates many of the values and components of the patient centered medical home.
At all sites, residents 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. Before each clinic session, residents participate in a pre-clinic conference, led by both a peer teacher and a core faculty member, which utilizes our internationally renowned Yale Office-Based Medicine Curriculum.
During the residents' continuity session, a 3 to 1 resident to faculty ratio is maintained and the faculty devotes their time exclusively to precepting. Typically, each resident will see 3-5 patients per half-day session as interns, 4-6 as PGY-II's, and 5-7 as PGY-III's. Incorporating a growing trend in residency training favoring a block scheduling system, residents will follow a “4 + 4” schedule, alternating 4 weeks of inpatient with 4 weeks of outpatient throughout the year. During general medicine rotations residents will attend their continuity practice once every other week in order to maintain contact with their panel of patients and the practice site staff. Faculty and residents work together in teams, with an emphasis on resident “practice partners” to ensure the highest possible continuity of care despite periods away from clinic for inpatient or international health rotations, or vacation.
With this high level of continuity, faculty can maintain quality of care and efficiency (since they also know the patients well), provide more substantive evaluations (since they observe the resident frequently over time), and precisely target their teaching (since greater continuity improves appreciation of residents’ learning needs). The patient visits include new patients, timely post-hospitalization visits, return visits and urgent care and include a broad range of internal medicine conditions.
Each member of the core faculty serves as the academic adviser for no more than six house staff, and complete biannual summative evaluations of their residents in accordance with the ACGME’s Clinical Core Competency evaluation process. This approach attends to resident achievement of observable, measurable developmental milestones, with data culled from various sources including direct observation (mini-CEXs), in-training exams, 360 degree evaluations, standardized patient workshops, chart-stimulated recall sessions, and informal feedback. In turn, residents have the opportunity to evaluate their preceptor’s teaching skills and the operations of the clinics such that there is an environment of collegial and collaborative continuous improvement.
Yale Adult Primary Care Center at St. Raphael’s CampusThe Adult Primary Center is located at the Chapel Street (St. Raphael’s) Campus of Yale-New Haven Hospital. An electronic medical record (EPIC) integrates all patient information from both the inpatient and outpatient settings and allows for seamless documentation and sharing of patient information among providers. Physical plant resources include built in audio-video equipment, direct web-access to the Yale Medical Library, and facilities for minor procedures. Weekly educational opportunities for trainees include an impressive number of on-site subspecialty clinics: a multidisciplinary diabetes disease management clinic, both dermatology and rheumatology clinics staffed by adjunct subspecialist faculty, a dedicated joint injection clinic, the Addiction Recovery Clinic (multi-disciplinary care including Suboxone prescribers and a behavioral change psychologist), the Transitions Clinic (dedicated hospital follow-up service), Pre-operative clearance clinic, a primary care psychiatry clinic staffed by a psychiatrist, and much more. The practice sees greater than 15,000 visits per year, providing care for medically underserved citizens of New Haven. Residents at this site also have the opportunity to participate at a nearby student health clinic at the University of New Haven.
West Haven Veteran's Administration Hospital
The VA COE in Primary Care Education trains future health care professionals in a team-based, patient-centered care teaching model. Through an innovative curriculum of interprofessional clinical care months, interactive leadership seminars, innovative research models, and health policy classes, the COE offers trainees a unique, transformative approach to post-graduate medical education. Trainees learn and care for patients within protected ambulatory care time where they focus on managing a panel of patients, exclusively seen by the COE members in a team based “practice partner” model. A daily focus of the experience is learning to practice in an environment that emphasizes interprofessional collaboration, health policy, leadership, and quality improvement - necessary skills to function in today’s health care system, irrespective of specialty choice.
Residents see their continuity patients in a grant-funded Veterans Administration Center of Excellence for Primary Care Education (VA-COE). The primary purpose of this center is to develop innovative ways to prepare health professionals to work in a Patient Centered Medical Home. Medical residents work in interprofessional teams (with nurse practitioners, nurses, medical assistants, pharmacists, health psychologists) to provide coordinated longitudinal care for veterans. The curriculum focuses on four educational domains related to patient-centered care.
- Shared Decision-Making: care is aligned with the values, preferences and cultural perspective of the patient; behavior modification and self-management is promoted.
- Sustained Relationships: curricula accommodate continuity of care and promote longitudinal learning relationships.
- Interprofessional Collaboration: care is team based, efficient and coordinated; trainees practice collaboratively.
- Performance Improvement: trainees learn to optimize the health of populations and understand the methodology of process and outcome assessment and CQI.
Nathan Smith Clinic
The Yale Internal Medicine HIV Training Track based in the Nathan Smith Clinic at Yale and Yale-New Haven Hospital is dedicated to training general internists in the core skills necessary to provide comprehensive primary care for the HIV infected patient. Practicing from within a multidisciplinary team, residents learn from faculty preceptors with expertise in both Primary Care and HIV medicine. Additional HIV training track experiences include rotations through a sexually transmitted infection clinic, a prison clinic, and a nearby methadone maintenance clinic in New Haven. For more details about this exciting new opportunity in the Yale Primary Care Program, please visit the HIV Track website. Of note, during ambulatory blocks, HIV Training Track residents also participate in a number of the clinical experiences offered at the Adult Primary Care Center at St. Raphael’s Campus.