Associate Professor of Medicine (General Medicine); Director, Addiction Recovery Clinic, Internal Medicine; Associate Program Director, Ambulatory Education, Yale Primary Care Residency Program, Internal Medicine; Co-Director, Racism, Bias, and Advocacy in Medicine Distinctions Pathway, Internal Medicine
Ambulatory Education
While the majority of healthcare delivery occurs in ambulatory settings, internal medicine residency training remains largely hospital-based. To address this imbalance between training and practice, the Yale Primary Care Program is committed to providing expanded and uncompromised ambulatory training. Innovative curricula ensure continuity of care with patients, continuous relationships with supervising faculty, diverse clinical settings, and experiential learning with graduated autonomy. In developing ambulatory experiences, we are guided by the insights of the medical education literature, a continual evaluation of our own work, local community health care needs, and residents’ feedback and individual goals. A commitment to advancing the science of graduate medical education is one of the important ties that bind the primary care program faculty. Indeed, our own research findings often directly inform our curriculum.
Our curriculum's broad objectives reflect the knowledge, skills, behaviors, and attitudes exemplified by effective primary care physicians. In addition, we have developed curricula to cover newer areas of proficiency for internists, including quality improvement, disease management, evidence-based practice, shared decision-making and patient-centered, interprofessional team-based care.
The residents’ continuity clinic and ambulatory block rotations represent the cornerstones of their ambulatory experience. In addition, about half of the activities on elective rotations take place in outpatient venues.
Ambulatory Education Leadership
Associate Professor of Internal Medicine (General Medicine); Program Director, Yale Primary Care Residency
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Ambulatory Objectives
Skills and Behaviors
Residents will:
- Evaluate and manage patients with the range of problems encountered by primary care physicians
- Address health care maintenance issues for adult patients
- Cultivate the robust set of physical examination skills essential to the practice of outpatient internal medicine
- Perform primary care procedures, such as joint injection, skin biopsy, and dermatologic cryotherapy
- Demonstrate communication skills necessary for effective medical interviewing and patient counseling
- Orchestrate the longitudinal care of primary care patients, including follow-up, telephone medicine, and collaboration with consultants, nutritionists, social workers and various community services
- Develop systems to convert their emerging information needs into well-formed clinical questions and to efficiently acquire, appraise, and apply medical information
- Exemplify the highest standards of ethics in patient, professional, and interpersonal interactions
- Efficiently provide patient-centered care as part of an interprofessional team within a practice microsystem
- Accurately document and code for care provided in an electronic medical record
Knowledge
Residents will:
- Understand the presentation, evaluation, and management strategies of chronic diseases and acute illnesses encountered by primary care physicians
- Understand the basic principles for interpreting diagnostic tests, including probability revision and cost-effectiveness
- Understand the health care system in the United States and Connecticut (and proposed reforms) and its impact on the provision of primary care
- Appreciate core values of the Patient Centered Medical Home care model
Attitudes
Attitudes
Residents will:
- Appreciate the rewards and responsibilities of assuming the primary care of a group of patients, including the importance of patient advocacy
- Consider their role as primary care physicians in the larger contexts of medicine in general, society, and their family and social networks
Continuity Clinic
In order to meet the individual interests and career goals of our residents, we offer two unique continuity clinic settings. These include the New Haven Primary Care Consortium located at 150 Sargent Dr. (the main practice site for the Yale Primary Care core faculty) and the Nathan Smith Clinic, which serves as the primary site for our HIV primary care training track. Each of these sites incorporates many of the values and components 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 Yale's Section of General Medicine, Department of Internal Medicine. Before each clinic session, residents participate in a pre-clinic education or multidisciplinary huddle.
During the residents' continuity session, a 3-1 resident to faculty ratio is maintained and the faculty devotes their time exclusively to precepting. Typically, each resident will see 3-5 patients per half-day session as interns, 4-6 as PGY-II's, and 5-7 as PGY-IIIs. Incorporating a growing trend in residency training favoring a block scheduling system, residents will follow a “6+2” schedule, alternating 6 weeks of inpatient/elective/private ambulatory offices or ED with 2 weeks of outpatient throughout the year. During inpatient rotations residents do not attend their continuity practice, to allow them to focus on inpatient management. Faculty and residents work together in teams, with an emphasis on resident “practice partners”to ensure the highest possible continuity of care despite periods away from clinic for inpatient or international health rotations, or vacation.
With this high level of continuity, faculty can maintain quality of care and efficiency (since they also know the patients well), provide more substantive evaluations (since they observe the resident frequently over time), and precisely target their teaching (since greater continuity improves appreciation of residents’ learning needs). The patient visits include new patients, timely post-hospitalization visits, return visits and urgent care and include a broad range of internal medicine conditions.
Each member of the core faculty serves as the academic adviser for no more than three house staff, and complete biannual summative evaluations of their residents in accordance with the ACGME’s Clinical Core Competency evaluation process. This approach attends to resident achievement of observable, measurable developmental milestones, with data culled from various sources including direct observation (our Skill Tracker app), in-training exams, Multi-source feedback evaluations, standardized patient workshops, chart-stimulated recall sessions, and informal feedback. In turn, residents have the opportunity to evaluate their preceptor’s teaching skills and the operations of the clinics such that there is an environment of collegial and collaborative continuous improvement.
New Haven Primary Care Consortium at 150 Sargent Drive
The Adult Primary Care Center is located at the New Haven Primary Care Consortium at150 Sargent Drive in New Haven. An electronic medical record (EPIC) integrates all patient information from both the inpatient and outpatient settings and allows for seamless documentation and sharing of patient information among providers. Physical plant resources include built in audio-video equipment, direct web-access to the Yale Medical Library, and facilities for minor procedures. Weekly educational opportunities for trainees include an impressive number of on-site subspecialty clinics: a multidisciplinary diabetes disease management clinic, both dermatology and rheumatology clinics staffed by adjunct subspecialists, the Addiction Recovery Clinic, the Transitions Clinic, clearance clinic, a primary care psychiatry clinic, and much more. The practice sees greater than 15,000 visits per year, providing care for medically underserved citizens of New Haven. Residents at this site also have the opportunity to participate at a nearby student health clinic at the University of New Haven.
Nathan Smith Clinic
The Yale Internal Medicine HIV Training Track, based in the Nathan Smith Clinic, 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.