Traditional Internal Medicine Residency Training Program
Ambulatory Education
Education in Ambulatory Medicine is provided through three types of experiences, Ambulatory block rotations, resident Continuity Clinics and rotations in Emergency Medicine.
Ambulatory Block rotations:
The Ambulatory Block rotations in each of the three years of residency training provide the corner stone of the Program’s ambulatory education for its residents. Home access is available to the computer system to follow-up on laboratory test results and to learn about patients when being on “telephone call” as a second year resident.
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Ambulatory block rotation for Interns:
Categorical interns have two 4-week block rotations, the one at the V.A. Hospital being a non call month and the other at Yale being a call month on a very special service called the Generalist Team (see below under Inpatient Education) set up to provide continuity in the care of patients as they transition from inpatient to outpatient care. Preliminary Interns do not have the call ambulatory block rotation which the categorical interns have at Yale, but they do have exactly the same non-call rotation that the categorical interns have at the V.A. Hospital.
- V.A. Hospital Ambulatory Rotation: This is a non call rotation. The goal is to provide interns with immersion in outpatient medicine under close supervision. A variety of experiences are provided such as first interaction with patients coming for an urgent visit, focused care for patients discharged recently from hospital who come in mainly for very specific follow-up, patients in subspecialty outpatient clinics and the medical care of patients with strokes. Didactic teaching sessions in very small groups occurs daily on outpatient general internal medicine topics, often based on patients seen. In addition, sessions are held by those with careers in Clinical Research on the elements of clinical epidemiology, with a focus on providing interns with the basic tools essential to being able to review medical literature critically.
- Yale Ambulatory block rotation for Interns: This is a unique rotation for categorical interns that runs in tandem with the inpatient rotation on the Generalist team, which is the inpatient team at Yale that admits patients who belong to the residents’ continuity clinics. Its main goal is to provide a continuity experience between patients whose care moves from an outpatient to an inpatient setting and vice versa. It is therefore a call rotation, the outpatient ambulatory block intern taking call once every four days, admitting patients to the Generalist team. Some of the special features of this rotation are:
- Exposure to urgent visit clinic patients
- Attendance at subspecialty clinics
- A weekly conference where outpatient and inpatient (Generalist team) interns and residents, Attending Physicians, Chief Resident and support staff meet to discuss the follow-up of patients discharged from hospital in recent weeks.
- Didactic lectures on topics related to the practice of outpatient medicine.
- Community Van: Two residents join a supervising attending on the community van which provides outreach care to neighboring indigent patients who may not otherwise be able to seek medical attention. The community van services neighborhoods in New Haven where access to medical care is otherwise limited.
- Neurology clinic: There is a neurology clinic attached to the residents’ ambulatory medicine clinic, and on an appointed day the residents attend this clinic and present the patients they see to a neurologist
- Telephone Medicine: in internship, during the ambulatory block rotation, interns receive training in telephone interactions with patients and are actually cal patients to provide them with follow-up information. This activity is taken to a much higher level commensurate with the level of training and the second year resident takes home “telephone call” for patients who attend resident clinics, and is expected to respond to patient’s inquiries, requests for prescriptions etc. There is always an Attending Physician available to respond to the resident’s concerns should there be any. Since each resident has home access to the outpatient computer system, they have access to medical records.
Ambulatory block rotation for second year residents
The second year residents have a 4 week Ambulatory rotation at Yale. During this time they participate in all of the activities that the interns do, but are giving greater clinical responsibility commensurate to their level of training. In addition they participate in the following two additional activities:
- Quality Assurance Program: This is highly regarded conference series and hands-on activity. Through a combination of small group lectures, independent reading, and a novel chart audit experience, the second year residents learn various concepts in the measuring of and improvement in the quality of their own clinical practices. Using diabetes as a paradigm, the residents become familiar with the development of practice standards, investigate barriers to their implementation, and ultimately learn to improve their own practices and the clinic environment in which they work. Lectures, or more often interactive sessions, are supplemented by independent reading and time spent working on chart audits. The audits target a small group of patients with diabetes that the residents are following in their own continuity clinics. Each resident is expected to conduct a total of 5 chart reviews during the month, and through this process collect various outcome and process measures to determine how closely they are in compliance with the published ADA practice parameters. Finally, at the end of the month the residents are expected to submit their completed audits as well as a “commitment to change form”. On this form they are asked to identify various areas that they feel need improvement in their own patient care practices, how motivated they are to make a change, and how difficult they think making a change will be. At a future date the residents are then contacted to see if they have made progress in the areas they identified, and if not, to make an effort to determine what barriers they have encountered in making a change.
Ambulatory block rotation for third year residents:
Third year residents have a very unique 2 week ambulatory block rotation. They spend some of the time in the general internal medicine practice of one of our general internal medicine faculty at Yale, they have time allocated to do chart reviews on their own Continuity Clinic patients to assess the quality of care rendered to patients with specific diagnoses over the two to three years of residency training, they prepare for journal club under the guidance of a faculty member who is a clinical investigator and they undertake preceptorship and teaching of interns in their Continuity Clinics in a supervised setting and receive feedback on their pedagogic skills.
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 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 syllabus that covers a wide span of primary care topics, known as the Yale Office-based Medicine Curriculum. 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.
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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 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" internal medicine areas 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 based on annual surveys of residents and faculty. More than 150 residents and 70 faculty in the Yale Primary Care, Traditional, and Combined Medicine-Pediatrics Residency Programs currently use the curriculum. 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 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
Continuity Clinics:
The other setting where categorical interns and second and third year residents receive ambulatory education is of course in their weekly Continuity Clinics. Preliminary Interns do not have continuity clinics. Continuity clinics are run for the categorical interns and all second and third year residents at Yale and at the affiliated Veterans Administration Hospital or at a community setting. Fluency in Spanish is required for the clinic at the community setting. The spectrum of patients seen is vast.
The continuity clinics provide residents with the setting to develop their skills in longitudinal care for a personal panel of patients. Our residents have the opportunity to practice at one of a variety of high-quality sites. The majority of residents see patients in the Yale-New Haven Hospital-based Primary Care Clinic, where many of the local residents of New Haven seek care, or in the Primary Care Center at the West Haven VA Hospital. A few residents may choose to have their continuity clinics in other community-based clinics or as part of a community-based private internal medicine practice.
Each resident sees their patients one half-day per week during ward rotations and two half-days per week during ambulatory rotations. Each resident will deliver care under the supervision of an experienced, full-time academic internist who holds a position in the general medicine section of the Department of Medicine at Yale, and who has been selected to precept residents' clinics based upon outstanding teaching skills and knowledge of primary care. All precepting Attending Physicians are practicing internists and regularly participate in faculty development to refine and improve their ambulatory teaching skills.
At the beginning of the internship year, each resident is assigned a clinic preceptor who will be their “partner in care” for the duration of their residency. The resident will review each patient with their assigned preceptor and together they will agree on the appropriate plan. This interaction evolves over the 3 years of the residency as the resident's skills and knowledge grow. During internship, the preceptor will see each patient and confirm the pertinent findings of the intern's history and physical exam. This is a superb way to provide teaching targeted specifically to the strengths and needs of individual residents. As the resident gains experience and skill over time, the resident-preceptor interaction evolves to focus primarily on the issues the resident identifies as needing attention. The Attending Physicians are responsible for precepting an average of 4 residents during clinic and have no other competing obligations during that time. A resident's preceptor is available during the week on non-clinic days to answer questions and aid in patient care. Throughout the year, the preceptor will provide the resident with ongoing feedback based on direct observations, the purpose of which is educational and intended to contribute to hands-on learning in the ambulatory setting . Additionally, the residents have the opportunity to evaluate their preceptors and the clinic where they practice.
The curriculum is case-based, and is accompanied by challenging questions which emphasize practical aspects of diagnosis and management and the strength of the supporting data. The goal of these exercises is to stimulate problem solving and evaluation of new information, and to initiate meaningful discussion among clinic participants. The syllabus is provided to each resident on a CD ROM and the syllabus is revised and the bibliography updated each year. Each “chapter” is authored by a faculty member. The topics for the curriculum are chosen by faculty with resident input. They range from “bread and butter” internal medicine issues such as the outpatient diagnosis and management of patients with hypertension, diabetes, anemia, HIV etc. to cancer screening and immunizations to topics in diverse specialty areas such as orthopedics, rheumatology, women's health, dermatology, and psychosocial and economic aspects of medicine. As a testament to the high quality and unique features of this curriculum, over 25 residency programs across the United States are currently purchasing our curriculum for use in their own programs.
Emergency Medicine Rotations:
Emergency Medicine Rotation are for PGY-2 and PGY-3 residents only. In this 2-4 week rotation, residents work under the supervision of the full-time Emergency Department Medical Director and the faculty of the Section of Emergency Medicine. While on this rotation, residents spend an average of five twelve-hour shifts per week in the Emergency Department. Third year residents also spend a 2 week rotation in the Emergency room at the V.A. Hospital. This is a day time rotation and provides an outstanding experience with initial contact with patients who have acute illnesses, offering a fair amount of autonomy since residents are in their third year of training, but Attending level help is always available.