In order to meet the individual interests and career goals of our residents, we offer three unique continuity clinic settings. These include the Chase Outpatient Center (the main practice site for the Yale Primary Care core faculty); the VA Healthcare Center of Excellence in Primary Care Education, and, finally, a newly developed HIV primary care training opportunity –The Nathan Smith clinic. Each of these sites incorporates many of the values 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. The faculty preceptors participate in an ongoing faculty development program to refine their ambulatory teaching skills 1. 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, the faculty devotes their time exclusively to precepting and we maintain a 3 to 1 resident to faculty ratio. Typically, each resident will see 3-5 patients as interns, 4-6 as PGY-II's, and 5-7 as PGY-III's. An innovative faculty-resident schedule synchronization system ensures that residents work with the same primary preceptor each week, even as their clinic day moves to accommodate inpatient rotation structures and ACGME duty hours requirements. With this high level of continuity, faculty can maintain quality of care and efficiency (since they know the patients well), provide more substantive evaluations (since they observe the resident over time), and precisely target their teaching (since greater continuity improves appreciation of residents’ learning needs). The patient visits include new patients, return visits and urgent care and include a broad range of internal medicine conditions. There is an infrastructure in place to ensure that residents participate in their patients' care during unscheduled clinic time, emergency room visits, and hospital admissions.
Preceptors complete biannual summative evaluations of the residents, attending to their achievement of developmental milestones,2 and offer formative evaluations in the form of direct observations (mini-CEXs),3,4chart stimulated recall, and informal feedback. In turn, residents have the opportunity to evaluate their preceptor’s teaching skills and the operations of the clinics.
Henry S. Chase Outpatient Center
West Haven Veteran's Administration Hospital
The VA Connecticut Healthcare System (VACHS) Center of Excellence (COE) in Primary Care Education
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, 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. 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.
1Green ML, Gross CP, Kernan WN, Wong JG, Holmboe ES. Integrating teaching skills and clinical content in a faculty development workshop. J Gen Intern Med. 2003;18(6):468-474.
2Green ML, Aagaard EM, Caverzagie KJ, et al. Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training. Journal of Graduate Medical Education. 2009;1(1):5-20.
3Holmboe ES, Fiebach NH, Galaty LA, Huot S. Effectiveness of a focused educational intervention on resident evaluations from faculty a randomized controlled trial.[see comment]. J Gen Intern Med. 2001;16(7):427-434.
4Holmboe ES, Huot S, Chung J, Norcini J, Hawkins RE. Construct validity of the miniclinical evaluation exercise (miniCEX). Acad Med. 2003;78(8):826-830.