Developing the skills and expertise necessary for the practice of outpatient medicine is an essential component of residency training in both internal medicine and pediatrics. There is also growing recognition that essential aspects of office practice, such as doctor-patient-family communication, evidence-based decision-making, preventive medicine, and office-based procedures, should be taught to residents in training. An extensive ambulatory curriculum has been developed to meet these needs, and is learned in a variety of venues and rotations.
Med-Peds Continuity Clinic
Med-Peds housestaff have their continuity practices in a modern clinic built by St. Mary's Hospital in Waterbury specifically for this purpose. It is a combined clinic, caring for both adult and pediatric patients at all times. Resident practices are supervised by full-time Med-Peds faculty who are free from other scheduled responsibilities while precepting housestaff. Faculty also care for their own patient panels, drawn from the same local population, in the same clinic during separate sessions. New patients, ranging from newborns to nonagenarians, are recruited by faculty and housestaff from St. Mary's newborn nurseries, pediatric and adult in-patient wards, and from a growing panel of satisfied, ethnically diverse families. Referrals from the Waterbury area are also referred to the Med-Peds clinic from the nursery and subspecialy services at Yale. Within clinic the Faculty has developed clinical programs in HIV, Neonatal HIV, Hep C, narcotic addiction, refugee health, and the care of chronically ill children. These clinical enterprises further expand our residents' clinical training.
A nationally recognized pre-clinic conference series, developed by Yale faculty, addresses topics in both internal medicine and pediatrics. A local chapter of the nationally acclaimed Reach Out and Read program helps Med-Peds providers promote literacy amongst their patients. Additionally, initiatives to improve the quality of care in the clinic are routinely spearheaded by residents with faculty support and supervision. These resident initiatives are often the focus of our monthly Med-Peds noon conferences, which are organized by the Med-Peds Chief Resident.
Med-Peds Ambulatory Blocks
Med-Peds residents rotate through protected ambulatory blocks during all four years of training. These blocks are custom-crafted to help residents meet their individual educational needs. Residents work with faculty in advance of the rotations to determine the best use of the time. Early on in training, the ambulatory blocks are designed to help residents deepen their skills as outpatient physicians, develop familiarity with the critical roles that non-physicians play on the ambulatory care team, spend concentrated periods of time in continuity clinic, and begin working on a scholarly pursuit. Residents also spend time in the private offices of community-based internists, pediatricians, family physicians, and Med-Peds practitioners, where they gain exposure to the business and logistical aspects of practice management. As residents advance in training, the ambulatory blocks are increasingly customized to provide additional training in areas of personal interest and to lay the groundwork for life after residency. Great flexibility exists in developing the Med-Peds ambulatory blocks. Residents benefit from knowledge of the creative things their predecessors have done with the time, but ultimately no two resident schedules are identical given the broad range of resident interests and available opportunities.
Other Ambulatory Clinical Sites
Essential primary care skills are also taught during outpatient block rotations and electives. Throughout the four years, acute ambulatory care is learned alongside pediatric housestaff at Yale's Primary Care Center, and through adult and pediatric Emergency Medicine rotations. Pediatric and medicine outpatient electives include time in subspecialty outpatient clinics. Rotations in adolescent medicine, developmental pediatrics, and geriatrics also expose residents to core skills for outpatient Med-Peds practice.
Residents also have the opportunity to work in the VA Connecticut Healthcare System (VACHS) Center of Excellence (COE) in Primary Care Education which trains future health care professionals in a team-based, patient-centered care teaching model. Through an innovative curriculum of inter-professional clinical care months, interactive leadership seminars, and health policy classes, the COE offers trainees a unique, transformative approach to post-graduate medical education.
Ambulatory Education Lecture Series
The didactic component of the ambulatory curriculum includes the pre-clinic conferences, which provide practical, case-based reviews of common outpatient topics. During the ambulatory block, residents also participate in an Ambulatory Core Curriculum that includes a resident/faculty-taught evidence-based medicine series, and workshops on physician-patient communication skills, minor office procedures, and physical diagnosis. Also included are seminars in preventive medicine, psychosocial medicine, women's health, preoperative consultation, and outpatient management of common chronic diseases. There is a weekly ambulatory morning report in medicine, and a weekly series of outpatient pediatrics conferences which housestaff can attend when on outpatient rotations.
Residents also have an opportunity to participate in community projects including a medical clinic established by Program faculty in a homeless shelter, a free-care van for the uninsured in Waterbury, and community health promotion and disease prevention projects. Residents may also contribute to an annual month-long basic science review/career counseling course for minority college students who will be applying to medical school that is sponsored by the Primary Care Residency Program and the Office of Multicultural Affairs.
There are several other educational activities of relevance to ambulatory medicine and pediatrics. Some examples include high quality journal club series in both the Medicine and Pediatrics departments, a quarterly ethics series in Pediatrics, and a monthly Med-Peds noon conference.
Residents learn to assess and manage common problems in ambulatory care in clinic under the supervision and guidance of their faculty preceptors. To enhance this clinical experience and supplement any gaps in their firsthand encounters, we developed a literature-based curriculum that covers a wide span of primary care topics in pediatrics.
The YOBM and PCPC serve as the basis for the weekly pre-clinic conference that takes place in the half hour prior to resident continuity clinic. This conference is led by either a faculty preceptor or a resident under faculty supervision. Residents read the cases and key reference materials prior to coming to pre-clinic conference, which minimizes the amount of didactic information to be covered and enables vigorous discussion of the questions posed in the cases. The groups are small (including only residents, students, and faculty who have clinic that day), which facilitates active discussion and personalized education.
The curricula serve as a guide for organized, case-centered, evidence-based discussions of core topics in outpatient medicine and pediatrics as well as issues relating to the ethical, legal, and business aspects of healthcare. Through use of the curriculum, we ensure the quality, content, and accuracy of pre-clinic conference sessions from week to week. The curricula are available to Yale housestaff and faculty in both paper and online versions, both of which contain internet links to reference articles and useful resources.
Each chapter of both YOBM and PCPC is arranged in a standardized format: a case vignette followed by a series of questions. A moderator's version (“answer key”) also contains suggested answers to the questions, teaching pearls, and suggestions for group exercises to reinforce key points.
These innovative curricula were collaboratively developed by Yale housestaff and faculty to fortify evidence-based learning in our clinical conferences. All original content was in fact written by Yale housestaff and faculty, and continues to be updated annually. The curricula are used by over a 100 Med-Peds, Internal Medicine, Pediatrics, and Family Medicine residency programs nationwide, and have met with a high level of satisfaction based on surveys of residents and faculty. Med-Peds residents frequently serve as chapter co-authors with faculty, an opportunity that allows for scholarship, mentorship, and a richer understanding of a specific topic of interest. A full list of topics available can be found at the websites for each curriculum: yobm.yale.edu and pcpc.yale.edu.