Residency Continuity Clinic/Acute Care Clinic Curriculum

 

Relevant Rotations and Course Directors:

Downtown Health Plaza Acute Care Clinic (Director: Jim Wofford, MD)

Downtown Health Plaza Residency Continuity Clinics (Director: Jim Wofford, MD)

Outpatient Department Acute Care Clinic (Director: Sonal Singh, MD)

Outpatient Department Residency Continuity Clinics (Director: Sonal Singh, MD)

 

Overview:


Wake Forest University Health Sciences has two resident clinic sites, the Outpatient Department (OPD) of North Carolina Baptist Hospitals and the Downtown Health Plaza (DHP), a community-based practice.  Both sites have an acute care clinic to meet the urgent needs of its patient population.  Every month, each acute care clinic is staffed by one upper level resident (HO-2 or HO-3) and one or two interns (HO-1) who work under the supervision of an attending physician.  Supervision for interns is also provided by the upper level acute care resident.

All categorical/primary care residents also have a weekly continuity clinic where they follow a panel of patients over their three years of training.  Continuity clinics are supervised by faculty members from the Department of Medicine.  A ratio of at least one attending physician for every five residents is maintained.   Residents are organized in teams according to their continuity clinic day.  Clinic teams collaborate in providing cross coverage when a team member is not available and work together on educational and quality improvement projects. 

In the continuity and acute care clinics, the housestaff are responsible for seeing the patients, formulating appropriate differential diagnoses and management plans, and discussing each patient with the attending physician to determine the best therapeutic strategy.  Housestaff must provide or coordinate appropriate follow-up of lab studies and patient management and collaborate with the clinic’s multidisciplinary team. 

 

Principle Teaching/Learning Activities:

  • Morning Report (MR): Four mornings each week (M,T,W,F) from 8:00 to 9:00 AM all upper level residents meet with the ACMs, program director, chair of medicine and a Professor of the Week (POW) to discuss one or two patients recently admitted to the teaching services or seen in the outpatient clinics.  Interns on outpatient or elective rotations are required to attend as well.  Patients are presented by either a HO2 or HO3 and the ACMs lead the discussion.  The focus of the discussion is selected by the presenting resident in collaboration with the ACMs.  Some cases may be presented to discuss differential diagnoses, while others are presented to discuss specific management, medical ethics, or systems of care issues.  Ambulatory case’s are presented and discussed as well.

  • Intern Time Out Groups (ITO):  Interns meet with a “Time Out” group monthly.  Time Out groups are headed by a member of the residency program leadership.  Groups discuss the humanistic attributes of medical practice, including ethical dilemmas, interpersonal skills, professionalism, and personal life balance.

  • Intern Core Curriculum (ICC):  All interns complete this two semester curriculum during an ambulatory rotation in the first half and second half of the HO-1 year.  The curriculum is organized around 4 courses:  Evidence-Based Practice, Systems Based Learning, Advanced Communication Skills, and Professionalism.  Each class is held weekly and is led by a member of the residency program leadership.  As part of the curriculum the interns also participate in the “Community Plunge”.  The “Community Plunge” is a driving tour through Winston-Salem in which interns see the different neighborhoods in the community and learn about community resources.  The “Community Plunge” concludes with a focus group session at one of the local agencies.

  • Pre-Clinic Conference (PCC):  Before every afternoon clinic session, all housestaff in clinic meet for this 30 minute case-based conference.  The conference is led by a house officer with an attending present to serve as a resource.  The curriculum rotates over a three year period so that all major outpatient topics are covered during each resident’s 36 months of training.

  • Case-Based Teaching (CBT):  Every patient seen is presented by the housestaff to the attending physician.  In the course of these discussions, the attendings offer teaching points centered on diagnostic skills and strategies, clinical medicine, and disease state management.  Upper level residents in acute care also provide teaching and supervision for interns and medical students.

  • Noon Conferences (NC):    Housestaff in the Acute Care Clinics are required to attend a minimum of 60% of these core educational conferences.

  • Medical Grand Rounds (MGR):   Medical Grand Rounds are scheduled every Thursday 8:00 to 9:00 AM from September through the first week of June.  Expert speakers present clinically relevant topics.

  • Quality Improvement Projects (QIP):  Housestaff participate in a quarterly continuity clinic-based quality improvement project.  Residents are encouraged to participate in the development and implementation of the projects.



Principle Educational Goals by Relevant Competency
In the tables below, the principle educational goals for the Acute Care Clinics are indicated for each of the six ACGME competencies.  Because educational goals vary by level of training, the tables indicate the targeted year of training and the most relevant principle teaching/learning activities for each goal, using the legend below.

 

*Legend for Learning Activities

MR-Morning Report

ICC-Intern Core Curriculum

ITO- Intern Time Out

QIP-Quality Improve. Projects

PCC-Pre-Clinic Conference

MGR-Grand Rounds

CBT-Case-Based Teaching

NC-Noon Conferences

 

 

 

1)     Patient Care

** Please see Appendix A for specific patient care skills

 

Principle Educational Goals

HO Level

Learning Activities*

Effectively interview ambulatory patients

1, 2, 3

CBT, NC, PCC, ICC, ITO

Effectively examine ambulatory patients

1, 2, 3

MR, CBT, PCC, NC, MGR

Efficiently set the agenda for each visit

1, 2, 3

MR, CBT, ICC, ITO

Understand and implement appropriate strategies for disease prevention and health promotion

1, 2, 3

MR, CBT, PCC, NC, MGR

Learn and employ strategies to efficiently evaluate and manage common ambulatory medical problems

1, 2, 3

MR, CBT, PCC, NC, ITO, MGR

Appropriately triage and arrange follow-up for ambulatory patients

2, 3

MR, CBT, PCC, NC, MGR

Learn indications for common office procedures

1, 2

MR, CBT, PCC, NC, MGR

Perform and teach common office procedures

2, 3

CBT, PCC

Effectively coordinate a healthcare team to deliver effective care

2, 3

MR, CBT, ICC, PCC, ITO,  NC, MGR

 

 

2)  Medical Knowledge

     **Please see Appendix B for specific organ-based and symptom-based learning objectives**

 

Principle Educational Goals

HO Level

Learning Activities*

Expand knowledge of the basic and clinical sciences needed to effectively care for ambulatory patients

1, 2, 3

MR, CBT, ICC, PCC, NC, MGR

Learn evidence-based medicine strategies to access and critically appraise scientific information relevant to ambulatory patient care

1, 2, 3

MR,CBT, ICC, PCC, NC, MGR

 

 

3) Practice-Based Learning and Improvement

 

Principle Educational Goals

HO Level

Learning Activities*

Identify gaps in personal knowledge and skills in the care of ambulatory patients

1, 2, 3

MR,CBT, PCC, NC, MGR

Develop real-time strategies to fill knowledge gaps that will benefit patients in a busy practice setting

1, 2

CBT, ICC, PCC, ITO

Learn and practice quality assurance/quality improvement methods to enhance the quality of  care delivered in a practice

1, 2, 3

ICC, PCC, QIP

Participate in the education of colleagues to enhance the practice’s quality of care

1, 2, 3

MR, PCC, QIP

 

 

4) Interpersonal Skills and Communication

 

Principle Educational Goals

HO Level

Learning Activities*

Demonstrate effective and culturally-sensitive communication skills with patient and families from diverse backgrounds.

1, 2

CBT, ICC, PCC, ITO

Communicate effectively with health care colleagues to assure the delivery of comprehensive patient care.

1, 2, 3

CBT, ICC, PCC, NC, ITO

 

 

5) Professionalism

 

Principle Educational Goals

HO Level

Learning Activities*

Understand the qualities and components of professional behavior.

1

ICC, ITO, PCC, CBT

Behave professionally toward patients, families, colleagues, and all members of the health care team

1, 2, 3

MR,CBT, ICC, PCC, ITO

 

 

6) Systems-Based Practice

 

Principle Educational Goals

HO Level

Learning Activities*

Be knowledgeable of the resources available in the health care system and community to optimally care for ambulatory patients

1, 2, 3

MR,CBT, ICC, PCC, NC, ITO, MGR

Understand the principles and advantages of chronic disease management strategies

2, 3

MR, CBT, PCC, NC, MGR

Collaborate and organize a health care team to meet the needs of ambulatory patients

1, 2, 3

CBT, ICC, PCC, NC, ITO

Utilize the Electronic Health Record to provide effective and comprehensive care

2, 3

CBT, PCC

Use evidence-based, cost-effective strategies in the care of ambulatory patients

1, 2, 3

MR,CBT, ICC, PCC, NC, MGR

Be aware of the business aspects of practice management in the private and public sectors

2, 3

CBT, PCC, NC, ITO

 

 

Recommended Resources

1.     Each house officer should read the weekly material in the Pre-Clinic Conference manual distributed quarterly.  The manual includes a collection of clinically relevant publications from peer-reviewed journals.

2.     During the Acute Care Block, we recommend that each resident read through the  General Medicine syllabus of MKSAP 14 during the month-long rotation.

3.     We recommend that UpToDate be used as an evidence-based resource for practice-based learning to answer questions which come up during patient-care activities.

4.      Additional references include:

  • Barker, Burton, Zieve.  Principles of Ambulatory Medicine, 6th Edition.

  • Greene, Griffin. Essentials of Musculoskeletal Care, 3rd Edition.

  • Fitzpatrick, Johnson, Wolff, Suurmond. Color Atlas & Synopsis of Clinical Dermatology, 4th Edition.

  • US Preventive Services Task Force: Guide to Clinical Preventive Services. 2008

  • First Line reference for community resources in Forsyth County

  • Web-based resources on ViviDesk, PDA and through library

  • Alcohol Screening and Brief Intervention

  • Smoking Cessation Module (NW-AHEC)

  • Domestic Violence Screening

Evaluation Methods

Evaluations are based on personal observations by the clinic faculty of the resident’s performance in the outpatient clinical settings.  Medical knowledge is also assessed based on the resident’s contributions during didactic teaching sessions including the pre-clinic conference series and case-based teaching moments.  All residents also complete the in-training examination which includes a general internal medicine section.  These factors serve as the basis for completing the standard Department of Medicine resident evaluation form. The completed evaluation is then sent to the medicine program director for review.

 

In addition, a 360 degree evaluation is completed for each resident twice a year.  The 360 degree evaluation includes input from clinic secretaries, nursing assistants, and staff nurses.

 

APPENDIX A

 

Specific Learning Objectives in Patient Care:

Residents should demonstrate mastery of the following tools, skills, and procedures:

 

History, Counseling and Physical Examination

  • Screening tools for depression, anxiety, domestic violence and dementia

  • Approaches to motivational interviewing

  • Risk factor assessment and counseling for common chronic medical conditions

  • Interview approaches to assess and improve adherence to recommended therapy

  • Use of interpreters in the bilingual interview

  • Musculoskeletal examination: neck, shoulder, wrist, low back, hip, knee, ankle

  • Diabetic foot examination

  • Peripheral vascular examination

  • Pelvic Examination

  • Hall-Pike maneuver for vertigo

  • Screening Neurologic examination

  • Skin examination for malignancy

Procedures

  • Large joint aspiration and injection

  • Trigger point injection

  • Skin scraping and biopsy (shave and punch)

  • Cryotherapy for benign skin lesions

  • Splinting: wrist, hand and ankle

  • Wet preps for bacterial vaginosis and candidiasis

  • Incision and drainage of abscess

  • Urinalysis

  • Cerumen removal

 

APPENDIX B

 

Most common disorders presenting to the outpatient clinics:

 

Residents should understand the diagnosis, evaluation, and management of:

  • Preventive medicine, including screening and immunizations

  • Hypertension

  • Coronary artery disease/chest pain

  • Palpitations and syncope

  • Congestive heart failure

  • Peripheral vascular disease and aortic aneurysms

  • Anticoagulation

  • Diabetes mellitus

  • Hyperlipidemia

  • Hypo/hyperthyroidism and thyroid nodules

  • Osteoporosis

  • Obesity

  • Chronic obstructive pulmonary disease

  • Smoking cessation

  • Acute bronchitis

  • Upper respiratory infections/sinusitis/pharyngitis

  • Allergic rhinitis

  • Chronic cough

  • Asthma

  • Headache/Migraine

  • Vertigo, tinnitus, hearing loss

  • The red eye

  • Major depression

  • Anxiety disorders

  • Alcoholism and substance abuse

  • Somatoform disorders and medically unexplained symptoms

  • Back pain

  • Arthritis/joint pain including gout

  • Urinary tract infections/pyelonephritis

  • Incontinence

  • BPH and prostate cancer

  • Chronic renal disease

  • Gastroesophageal reflux disease

  • Abdominal pain

  • Diarrhea

  • Abnormal liver tests/hepatitis

  • Anemia

  • Common Gyn conditions: vaginal bleeding, vaginitis, amenorrhea, PID, contraception, breast mass

  • Common skin disorders: cellulitis, eczema, contact dermatitis, acne, sun burn, seborrheic and actinic keratoses, pruritus, insect bites/stings, screening for skin cancer

  • Work assessment and disability determination

 

 

updated Feb 2009