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Home , Ambulatory care

Ambulatory Care Curriculum

The Educational Purpose Ambulatory care medicine provides residents with the opportunity to gain the knowledge, skills, behaviors and attitudes needed to function in the outpatient setting as competent general internists. As , general internists will be called on to evaluate a diversity of concerns and problems for from late adolescence through the end of life being mindful of each ’s social, familial and occupational circumstances. Residents must learn to distinguish conditions that they can readily diagnose and manage in the outpatient setting from more serious and life-threatening illnesses, which may be outside the scope of their expertise and require referral, sometimes urgent. Residents must learn to provide effective consultations for other specialties, including perioperative assessments for patients undergoing . Residents must be able to address health maintenance, including screening assessments for school entrance and employment and disability assessments. Residents must learn to coordinate care in the outpatient setting. Residents must effectively navigate the system, and understand insurer finances and government agencies in their role as patient advocates.

At the PGY-1 level, residents are expected to be aware of the competency areas and work to integrate them into their ambulatory practice under faculty supervision. At the PGY-2 level, they are expected to manage the competencies well with supervision from faculty attendings. At the PGY-3 level, they are expected to be able to independently meet the competencies with minimal or no direction from faculty attendings. PGY-3 residents should be able to effectively and independently counsel patients on prognosis and disease management.

Patient Care Goal #1: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Objective #1: Residents must be able to gather essential and accurate patient information to assess patient concerns, with special attention to the following presentations: Sore Throat Cough Red Eye Runny Nose, Nasal Congestion Headache Dizziness Abdominal Pain Flank Pain Nausea & Vomiting Myalgias Joint Pain PGY-1 Rash Itching Skin and soft tissue infections Hair loss Urethral discharge Earache Dyspnea Urinary Frequency and Dysuria Thyroid Enlargement Diarrhea Fatigue Obesity Low Back Pain Neck Pain Blood in urine Fever Dysphagia Abnormal bruising, bleeding Jaundice Scrotal Pain, Testicular Mass PGY-2 Breast lumps Edema Ringing in the ear Hearing Loss Positive PPD Abnormal Chest X-ray Vision Changes Palpitations Syncope Anorexia Weight Loss Constipation Rectal Bleeding PGY-3 Weakness Localized Weakness Memory loss Numbness, Tingling

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Anxiety Depression Domestic Abuse Insomnia Smoking Sexual Dysfunction Alcohol & other substance abuse Objective #2: Residents will be able to develop and carry out patient management plans by making informed decisions on diagnostic and therapeutic interventions, counseling and educating patients and their families, and preventing health problems or maintaining health based on patient information and preferences, up-to-date scientific evidence, and clinical judgment with special attention to the following illnesses or conditions: Pharyngitis Rhinitis, Sinusitis Otitis Media/Externa URI Bronchitis Conjunctivitis & Eyelid infections COPD Common & Migraine Headaches Benign Positional Vertigo PGY-1 Meniere’s Syndrome and Disease Atypical Chest Pain Mellitus Hyperlipidemia Preventive Health Care – Immunization Preventive Health Care – Disease Screening STI in Males and Females Gender-specific Health Back Pain Monoarthritis, Polyarthritis Sprains & Strains of Limbs Congestive Common Skin Conditions Common Conditions causing Pruritis Acute Cystitis/Pyelonephritis Lymphadenopathy Common Causes of Abdominal Pain Hernias PGY-2 Common Breast Conditions Common Causes of Jaundice Cysts & Subcutaneous Masses Goiter, Thyroid Nodules: Hyperthyroidism, Hypothyroidism PPD Screening and Positivity Scrotal Mass Abnormal Chest X-ray Nephrolithiasis Hematuria Acute Diarrhea Chronic Diarrhea Common Causes of Constipation Hemorrhoids – External and Internal Anorexia and weight loss Anemia Drug TIA, Stroke Autoimmune Disorders Alzheimer and other dementias PGY-3 Mood Disorders Anxiety and phobias Sleep Disorders Obesity Common allergic problems Patient Compliance, Non-adherence and other problems Domestic Abuse Erectile dysfunction Smoking Cessation Substance Abuse Problems Sexual Minority Issues Objective #3: Residents must competently perform and interpret the results of all diagnostic and therapeutic medical and invasive procedures considered essential after obtaining informed consent, with confidence and minimal discomfort to patients: Perform: Breast examination Pelvic examination including Pap smear and endocervical culture Interpret: PGY-1 EKG Chest X-ray Peripheral Blood Smear Gram stain of sputum Microscopic Examination of urine KOH & wet prep examination of vaginal discharge Interpret: PGY-2 Spirometry Objective #4: Residents must communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families.

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Residents must be able to counsel patients by providing clear, direct messages about the importance of a PGY-1 diagnostic test, behavior modification or ; as well as the rationale, perceived benefits and potential risks to the patient of these interventions. Residents must include patients in decisions regarding their health and treatment, including goals and PGY-2 related strategies. PGY-3 Residents must be able to assess a patient's adherence to the agreed care plan in a non-judgmental manner. Objective #5: Residents must work effectively with other health care professionals including those from other disciplines, to provide patient-focused care. Residents must demonstrate mutual respect and cooperation in working together with all health care PGY-1 providers and professionals in a team effort that serves the patient's interests. Residents must be able to function in the role of the primary care provider who is in charge of the patient's PGY-3 overall care. This entails communicating with all the consultants and the patient to coordinate a plan of care.

Medical Knowledge Goal #2: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Objective #1: Residents must demonstrate an investigatory and analytical thinking approach to clinical situations. Apply an open-minded, analytical approach to acquire new knowledge. Access and critically evaluate PGY-1 current medical information and scientific evidence relevant to their patients.

Access and critically evaluate current medical information and scientific evidence relevant to all areas of general ambulatory care . Develop clinically applicable knowledge of the basic and PGY-2 clinical sciences that underlie the practice of general ambulatory care internal medicine.

Apply an evidence-based approach to clinical problem solving, clinical decision making, and critical PGY-3 thinking in the ambulatory care setting.

Objective #2: Residents must know and apply the basic and clinical supportive sciences applicable to Ambulatory Medicine with special attention to: Preventive Medicine, including cancer Diabetes Mellitus prevention counseling and screening PGY-1 Hypertension Asthma COPD Hyperlipidemia Common outpatient infections Thyroid Diseases Common Skin Infections PGY-2 Low Back Pain Congestive Heart Failure Outpatient management of Vascular disease Peptic ulcer disease and GERD Chronic Kidney Disease PGY-3 Headache Management Counseling patients on CAM treatment Obesity integration

Practice-Based Learning and Improvement Goal #3: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Objective #1: Residents must locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems. Residents must be able to effectively access and review prior medical records - outpatient or relevant inpatient records for recently discharged patients to ensure continuity of care; demonstrate effective data gathering skills from relevant sources and maintenance of written or Electronic Medical Records. PGY-1 Residents must be aware of the resources available to obtain up-to-date information related to their patients' health problems at the various ambulatory care sites through which they rotate.

Objective #4: Residents must be able to analyze practice experience and perform practice-based improvement activities using a systematic methodology. Residents must be able to routinely and systematically review their patients' progress towards meeting health care maintenance and therapeutic goals. This includes developing a system to identify and follow-up PGY-2 on their patients' status, including laboratory, imaging, and results as well as consultant recommendations. PGY-3 Residents must incorporate a methodology for creating and tracking care plans in the medical record.

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Objective #5: Residents must be able to obtain and use information about the practice population for quality improvement and the development of a high-functioning Patient Centered Medical Home. PGY-1/ Residents must recognize national quality improvement goals and practice standards. PGY-3

Interpersonal and Communication Skills Goal #4: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Objective #1: Residents must be able to sustain therapeutic and ethically sound relationships with patients, their families, and colleagues. Residents must be able to engage patients and their families for return visits to facilitate ongoing PGY-1 ambulatory care. Objective #2: Residents must use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families. PGY-2 Residents must effectively utilize translators to communicate with non-English speaking patients. Objective #3: Residents must interact with consultants in a respectful and appropriate manner. Residents must be able to remain in charge of the patient's overall care while interacting with consultants PGY-3 in a respectful and appropriate manner. Objective #4: Residents must maintain comprehensive, timely, and legible medical records. Residents must be able to use an electronic medical record (EMR) for documenting and communicating PGY-3 patient information.

Professionalism Goal #5: Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society. Objective #1: Residents must demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues. Residents must be punctual in their attendance for scheduled patient care appointment and cognizant of time constraints. Residents must be willing to assist in smooth operations by responding when approached with PGY-1 problems. This includes helping their colleagues and seeing extra patients. Residents must be able to work with MAs, nurses, and other ancillary staff to coordinate patient care. Objective #2: Residents must show sensitivity and responsiveness to the gender, age, culture, religion, sexual orientation, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues. Residents must be culturally sensitive and appropriate in their care of underserved/culturally diverse PGY-2 patients.

Systems-Based Practice Goal #6: Residents must demonstrate both an understanding of the contexts and systems in which health care is provided and the ability to apply this knowledge to improve and optimize patient care. Objective #1: Residents must demonstrate an understanding of and the ability to access and utilize the resources, providers, and systems necessary to provide optimal care. Residents must be aware of the forces that impact the cost of health care and the principles of cost- PGY-1 conscious care and screening. Residents must be aware of, and identify various physical, psychological, social and financial barriers to appropriate care in the ambulatory setting. Residents must provide appropriate support to overcome such PGY-2 barriers, and enable patients to receive appropriate care. Residents must understand the principles of billing, and effectively manage financial procedures in the clinic setting. Residents must understand the forces that impact the cost of health care and apply principles of cost- PGY-3 conscious care and screening. Objective #2: Residents must be able to collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care. PGY-2 Residents must understand managed care systems including the prior authorization process. Residents must understand the role of primary care physicians in the healthcare system as gatekeepers and coordinators of care. PGY-3 Residents must understand the basic principles of the Patient Centered Medical Home, and what the role of the primary care is in the medical home. Residents must understand the PCMH-related quality measures, including PQRS and PDSA cycles. Objective #4: Residents must demonstrate the ability to initiate, coordinate, and facilitate discharge planning through the use of

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other health care professionals and systems resources. PGY-2 Residents must learn to work closely with ancillary staff to coordinate clinic discharge process.

The Teaching Methods • Yale Ambulatory Curriculum weekly modules • Program Conferences • Queen's Medical Center Grand Rounds • Ambulatory Journal Club • QEC CAM Conference • QEC Conference • QEC Outpatient Conference • QEC HIV Lecture • QEC PCMH Conference • Agency for Healthcare Research and Quality (AHRQ) Modules • Diabetes Mellitus In-service for residents • Coding and Billing for residents • Statistics • Attendance at clinic and meetings and committees as assigned (Medication and Nutrition committee, Internal Medicine staff meetings, monthly QEC staff meeting)

Types of Clinical Encounters, Procedures, and Services Residents will function in the outpatient setting, performing complete or focused history and physical examinations as appropriate to the clinical situation. They will see new and established patients, and assume responsibility for and coordinate all aspects of ongoing clinical care for primary care patients. Residents will also see patients in consultation in and provide consultation to other specialties. Residents will also perform procedures encountered on the rotation according to the guidelines and requirements in the Resident Handbook (see Section IV. D. Procedural Skills). Residents will interact with various members of the health care team including physicians from different specialties, medical students, other medical personnel and ancillary services as appropriate to the care of their assigned patients. Residents rotate at Queen Emma Clinics, VA outpatient general/specialty clinics, and other outpatient clinical sites.

Ancillary Education Resources Residents have access to most laboratory data reports; Xray, Ultrasound and other diagnostic imagings; EKGs, Echocardiogram, Pulmonary Function tests and other reports to support resident learning and patient care and also to specialists to consult with regard to interpretation.

Ambulatory Care Reading & Reference List

1. Barker LR, Fiebach NH, Kern DE, Thomas PA, Ziegelstein RC, Zieve PD, Principles of Ambulatory Medicine. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007. 2. Weinstock MB, Neides DM et al. Resident’s Guide to Ambulatory Care, 6th ed (or newer): Anadem Publishing, 2009. 3. Recommendations of the U.S. Preventive Services – full recommendation statements available at: http://www.uspreventiveservicestaskforce.org/recommendations.htm 4. Guide to Clinical Preventive Services, 2012 – available online at: http://www.ahrq.gov/clinic/pocketgd.htm 5. Articles linked to the Yale Ambulatory Curriculum weekly modules 6. Articles identified by the resident through focused literature searches based on clinical questions that arise in the care of their patients 7. Articles presented and discussed in the Ambulatory Journal Club 8. American Family Physician Journal 9. Strange, KC, Nutting PA et al. Defining and Measuring the Patient-Centered Medical Home. J Gen Intern Med. 2010 June; 25(6): 601–612.

Revised by Drs. Ashlee Nekoba and Dorothy Shigaki Reviewed and revised by Task Force Committee August 8, 2013 Approved by the Curriculum Committee August 9, 2013

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