The ambulatory medicine didactic curriculum of the Yale Primary Care Residency is among the most comprehensive and effective seminar series offered in any training program. Organized around 12 recurring outpatient medicine themes, the curriculum features lectures, interactive seminars, peer teaching, self-directed and experiential learning, workshops, and off-site experiences. Theme days may include Women's Health, Palliative Care, Disparities in Healthcare, HIV care, Neurology, Occupational Medicine, Lifestyle Medicine, Geriatrics, and Psychosocial Medicine. In addition to the focused thematic content on a given day, there are a number of longitudinal experiences that intercalate into several consecutive Monday theme days. These include the Evidence-Based Medicine Curriculum, the Musculoskeletal Workshop Series, the Ultrasound Curriculum, and the Community Engagement Curriculum, many of which are detailed below.
Addiction Medicine Training
Acknowledging the dominant role that both addiction and chronic pain play in the practice of medicine in the modern era, our ambulatory curriculum features a number of venues for exposing residents to the depth and breadth of this increasingly complex content area. The New Haven Primary Care Consortium features a weekly multidisciplinary Addiction Recovery Clinic1, staffed by two board-certified Addiction Medicine internists, a behavioral psychologist, a clinical social worker, and an addiction medicine fellow. All residents spend at least four half-days in this clinic each year, learning about the behavioral and pharmacologic management of patients with addictions to opioids, cocaine, alcohol, and other substances. Over the course of three years, residents undergo intensive training in the Screening, Brief Intervention and Referral to Treatment (SBIRT) model2 . In the first month of internship, all interns complete the buprenorphine training course required to become fully licensed buprenorphine prescribers. Through the Pre-clinic Teaching curriculum, residents benefit from didactic lectures from some of the preeminent experts in the field of addiction medicine, while also benefiting from experiential learning with visits to nearby methadone treatment centers, 12-step self-help groups like Alcoholics Anonymous, and conversations with “guests in recovery.” Finally, residents can spend elective and/or ambulatory time rotating at one of several Yale-affiliated addiction treatment centers or chronic pain management centers.
- Holt S, Segar N, Cavallo D, Tetrault J. The Addiction Recovery Clinic: A novel, primary care-based approach to teaching Addiction Medicine. Academic Medicine. 2017; 92:680-683.
- Tetrault JM, et., al. Developing and implementing a multispecialty graduate medical education curriculum on Screening, Brief Intervention, and Referral to Treatment (SBIRT). Subst Abus. 2012;33(2):168-81.
Community Engagement Curriculum
The YPC Community Engagement Curriculum1-4 encompasses a series of workshops and learning experiences that take place in a longitudinal manner over the course of the three-year training program. There are three main goals for this portion of our curriculum:
- Equip residents with the skills, knowledge, attitudes, and experiences they will need to become leaders in improving the health of their local communities in the future.
- Identify important information regarding social determinants of health (SDoH) that affect the local community and learn about reliable sources of data regarding these determinants.
- Learn about local and regional community health partnerships and other assets, and consider their ability to serve as patient-care resources and potential collaborators for health-related activities with the residency.
As a spin-off from the required portion of the curriculum, the Community Engagement Resident Advisory Committee (CERAC) serves as an additional resource for residents who are particularly interested in engaging in community-based work and advocacy efforts with partner organizations in New Haven.
Given our belief that community engagement is an important part of primary care training and practice, YPC has also developed a unique Chief Resident role: the Advocacy and Community Engagement Chief Resident.5 Following graduation, these individuals are selected to serve for one year as part of the typical Chief Resident team, with the additional responsibility of focusing (together with the Associate Program Director for Global and Community Health) on the interaction of YPC residents and the training program with the New Haven community at large.
- Rabin TL, Howell B, and Rosenbaum JR. Alliance for Academic Internal Medicine (AAIM) Academic Internal Medicine Week Precourse Making Our Learners and Faculty Champions of Social Justice and Promoting Health Equity for Our Patients, Baltimore, MD. Oral presentation - “An Engaged Community: Advocating for Health Equity Through Medical Education.” March 19, 2017
- Rabin T, Rosenbaum J, and Roy B. Alliance for Academic Internal Medicine Academic (AAIM) Internal Medicine Week, Baltimore, MD. Oral presentation - Training Our Future Doctors to Be Community Change Agents: Addressing the Social Determinants of Health through Active Community Engagement - “Yale Primary Care Residency Community Engagement Curriculum.” March 21, 2017
- Rosenfeld A and Rabin T. Society of General Internal Medicine Annual Meeting, Denver, CO. Poster presentation - “Home visits within internal medicine postgraduate medical education: The impact on patients and providers.” April 12, 2018
- Howell BA, Whitmire LR, Baidwan S, Kristal RB, Huot SJ, Rabin T, and Rosenbaum JR. Society of General Internal Medicine Annual Meeting, Washington, DC. Poster presentation - “Advocating for Change: A Description of an Advocacy Curriculum for Internal Medicine Residents.” May 9, 2019
- Howell BA, Baidwan S, Whitmire LR, Kristal RB, Rosenbaum JR, Huot SJ, and Rabin T. Society of General Internal Medicine Annual Meeting, Washington, DC. Poster presentation – “The Advocacy and Community Health Chief Resident: A Novel Position to Enhance Community Engagement.” May 9, 2019
YPC Diabetes Clinic
Residents and interns participate in the YPC Diabetes Clinic1-3 on Wednesday mornings during their ambulatory block rotation. Since 2004, the YPC outpatient practice has employed a novel, targeted primary care-based approach to diabetes care vis-a-vis this multidisciplinary, referral-based clinic model. Under this model, residents can conduct longer visits with an exclusive focus on providing comprehensive diabetes care to patients who have not met their HgbA1c goals; receive mentorship from general medicine faculty with expertise in diabetes care; and partner in real-time with a pharmacist, nutritionist, and social worker to enhance patient care. Patients are referred into this specialty clinic by their resident and faculty primary care physicians (PCPs) and remain enrolled until they achieve their individual HgbA1c goals, at which point they are discharged back to their PCPs for continued diabetes management.
The educational focus of the Diabetes Clinic is on teaching residents to work to the top of their license to provide enhanced care and support for patients with diabetes. Residents learn a variety of essential practical skills (e.g., instructing patients in proper use of equipment [glucometers and injectable medications], as well as identification and treatment of hypoglycemia), gain knowledge of advanced and patient-centered management strategies for individuals with type 1 and type 2 diabetes, have focused learning on evaluating and managing important co-morbidities and psychosocial barriers to successful self-management, and develop strategies to assess and reduce risk of the common macrovascular and microvascular complications of diabetes.
- Kansagara DL, Holmboe ES, Carr K, Huot SJ. Establishing a diabetes disease management program in a resident clinic (Abstract). J Gen Intern Med. 2005;20 (Suppl 1):31.
- Raveendran J, Chung G, Malm T, Huot S, and Rabin TL. American College of Physicians Annual Internal Medicine Meeting - Virtual Experience. Oral presentation – “Impact of a Multidisciplinary Diabetes Clinic on Resident Education.” (2021 National Abstract Competition Podium Winner) April 30, 2021.
- Raveendran J, Chung G, Malm T, Huot S, and Rabin TL. Society of General Internal Medicine Annual Meeting. Poster presentation – “Impact of a Multidisciplinary Diabetes Clinic on Resident Education.” April 22, 2021.
Musculoskeletal Workshop Series
Knowledge and proficiency at examining patients with musculoskeletal complaints is among the most essential skills of the general internist, yet teaching of this skill is often undervalued in medical training1 . In the Yale Primary Care Residency Program, we stress the importance of physical diagnosis in all settings, citing a number of arguments in its favor:
- In an increasingly cost-conscious health care system, competence and confidence in the physical exam is essential to avoiding over-reliance on expensive and often misleading radiologic tests and their commensurate “incidentalomas”, cumulative radiation exposure, and patient inconveniences
- Unlike knowledge of pharmacologic treatment modalities and laboratory testing, knowledge and skill at bedside physical diagnosis is timeless – skills learned today will serve the learner for the remainder of his or her career
- as argued by Abraham Verghese, the “laying on of hands” is a part of the timeless ritual of medicine that is lost when we instead focus on treating the “iPatient” 2
- unlike MRI machines, a physician’s hands and senses are with them at no cost, 24 hours a day, 7 days a week.
With these principles in mind, we have interspersed throughout the Ambulatory Friday Curriculum a Musculoskeletal Workshop Series3 composed of a collection of lectures and case-based workshops featuring standardized patients, one on one instruction, and a multimodal learning theory approach to teaching these essential skills.
- Herrle SR, Corbett EC Jr, Fagan MJ, Moore CG, Elnicki DM. Bayes' theorem and the physical examination: probability assessment and diagnostic decision making. Acad Med. 2011; 86(5):618-27.
- Verghese A. In praise of the physical examination. BMJ 2009; 339.
- Siddharthan T, Soares S, Wang H, Holt S. OSCE-based Teaching of the Musculoskeletal Exam to Internal Medicine Residents and Medical Students: Bridging the UME/GME Divide. Southern Medical Journal. In press.
Primary Care Research Curriculum
The Yale Primary Care program embraces the idea that leaders in primary care medicine should be given the opportunity to be leaders in general internal medicine research. Residents are encouraged to choose relevant primary care questions to investigate. Given the breadth of research conducted in the General Internal Medicine section at Yale, residents benefit from unrivalled opportunities for faculty mentorship. Protected time for research includes participation in the Research in Residency program, research elective time, and use of optional research half-days during ambulatory rotations. For more information, please visit our program's Resident Research and Scholarship page.
Psychosocial Medicine Curriculum
Studies estimate that 35% of patients in primary care practice have psychosocial, not biomedical, problems. Clearly, then, physicians must be grounded in the psychosocial, as well as the biomedical domains, in order to provide optimum care for their patients. The psychosocial domain encompasses 1) a patient-centered, as opposed to purely physician-centered, approach; 2) interviewing skills, including listening, empathy and an awareness of how one's own feelings, biases, responses, etc., affect the doctor-patient relationship; 3) a belief that all illnesses have psychosocial aspects that influence their cause, manifestation, course, and outcome; and 4) the skills to diagnose and treat common psychosocial problems, such as mood and anxiety disorders, somatoform disorders, substance abuse, domestic violence, and non-adherence. The psychosocial domain is complementary to the knowledge, skills, and attitudes of the biomedical domain. Incorporating both domains in clinical practice is the called the biopsychosocial approach, useful not only for patients with mental health problems, but for all patients.
Research shows that physicians who use a biopsychosocial approach to patient care have more satisfied and adherent patients, affect better health outcomes, are more professionally satisfied, and even have fewer malpractice suits! The Psychosocial Curriculum seeks to provide house staff with the knowledge, skills, and attitudes needed to be successful and fulfilled internists. This three-year curriculum includes didactic and experiential components led by internists, psychiatrists and psychologists. The didactic lectures in the ambulatory core curriculum are in the following areas: depressive disorders, anxiety disorders, somatization, post-traumatic stress disorder, obsessive-compulsive disorder, neuropsychiatry, psychosis, movement disorders, psychopharmacology, psychiatric epidemiology, organic brain disease, domestic violence, alcohol abuse, helping patients to change behaviors, dealing with difficult situations, primary care of gay and lesbian patients, helping patients improve adherence and spirituality in medicine.
Experiential components include 1) primary care psychiatry consultation clinic, 2) outpatient substance abuse center, 3) medical interviewing tutorials1, 4) behavioral change counseling consultation clinic, and 5) difficult patient workshop.
1 Fortin AH, Haeseler FD, Angoff N, et al. Teaching pre-clinical medical students an integrated approach to medical interviewing: half-day workshops using actors. J Gen Intern Med. 2002;17(9):704-708.