All residents receive extensive training in ambulatory care, including continuity medical clinics, subspecialty practices, walk-in clinics, emergency rooms and private practices. Residents are exposed to a broad variety of patients under close supervision of faculty with expertise in primary care and preventive medicine. Through the weekly conferences -- Ambulatory Care Seminars, Primary Care Morning Report and Noon Core Conferences -- residents expand their knowledge of primary care and its related disciplines. The Associate Program Director for Ambulatory Education and the Primary Care Chief Resident are responsible for development and implementation of the ambulatory curriculum.
Continuity Medical Clinics
Residents participate in a continuity medical clinic starting in the beginning of their residency. Clinic sites include University Health Center (UHC), the Primary Care Clinics at the VA, the Faculty Practice Office (FPO), and Mercy Medical Center. Based on resident focus groups and surveys, our current scheduling for the residents' continuity clinics is structured such that residents do not attend clinic during busy rotations or when on long call, and have more clinic sessions when on elective or their Ambulatory Blocks. During the coming year, we will revisit this structure and explore moving to a 6+2 system. Having resident input into this decision is critical for how clinics will be structured for July 2017. Our continuity clinics continue to be a positive clinical and educational experience for the residents where they establish a 3-year relationship with their attendings, while ensuring balance with their other clinical responsibilities.
At each clinic site, residents develop a close working relationship with their colleagues and the general medicine faculty, who are expert at providing one-on-one supervision in primary care. All clinic sites provide easy access to laboratory and radiologic studies, medical records, and electronic resources, such as Up-to-Date. All clinics have an electronic medical record system with most using EPIC and the VA using CPRS. A bi-weekly noon clinic conference provides residents with a comprehensive curriculum in primary care and preventive health.
We started a new rotation for interns in July 2016, called Academic General Internal Medicine. During this 2-week block, interns spend every afternoon at their continuity clinic acclimating themselves to the ambulatory setting and adding patients to their panel. During the mornings, they do a variety of educational activities, including simulations, ultrasound skills, literature in medicine, IHI modules (for learning patient safety and quality improvement), interdisciplinary immersion (shadowing nurses), and attending a Risk Management meeting. The interns complete their Academic GIM block by November thus giving them a strong foundation for the rest of their intern year.
Ambulatory Block Rotations
Residents complete four Ambulatory Block Rotations (ABR's) during their upper years of training where they spend additional time in their continuity clinics. They enhance this experience with individualized schedules that include medicine subspecialty clinics and exposure to women's health, geriatrics and neurology. Residents complete their patient safety and quality improvement projects and practice based learning (PBL's) exercises during these rotations as well. Residents attain expertise in primary care and are exposed to important skills for achieving competency in internal medicine. They rotate through various sites, both at the academic medical center and at private practices in the community.
Residents have a wide range of choices during their Ambulatory Block rotations. If they are planning on a career in a subspecialty, they can attend outpatient clinics in that field or in one that complements that area of study. For example, a resident interested in oncology may choose an outpatient clinic in infectious diseases, in addition to attending clinic sessions and Tumor Board at the Greenebaum Cancer Center. Those interested in cardiology may attend clinics in advanced heart failure, general cardiology or EP. Residents interested in primary care choose components to enhance their skills in women's health, orthopedics, rheumatology, ENT, travel medicine, ophthalmology and dermatology. Residents may spend time in a private practitioner's office to get exposure to "real life" primary care and learn the business of medicine.
Required components of the Ambulatory Blocks include geriatrics, neurology, psychiatry, literature in medicine, and completion of practice based learning exercises.
- During Geriatrics, residents learn how a multidisciplinary team addresses the elderly patient's medical, psychological and social concerns.
- In the Neurology clinic and private practices, residents evaluate and manage problems such as chronic seizure disorders, peripheral neuropathy, movement disorders and headaches.
- Residents participate in Psychiatry Seminars, where they learn skills in treating common outpatient psychiatric problems, such as depression and personality disorders.
- A very popular component of the Ambulatory Blocks is the weekly Literature in Medicine Seminar. Led by a faculty member, the residents read and discuss the works of various authors and poets, reflecting on how the writings apply to the practice of medicine and the humanistic aspects of our profession.
- During Women's Health, residents receive instruction by general internists in pelvic and breast examinations and discuss hormone replacement therapy, abnormal PAP smears and identification of domestic violence.
- Most residents spend time in a private general internal medicine practice in the community where they gain exposure to a different patient mix and learn the principles of continuity and episodic care from experienced practitioners.
- Residents participate in a problem based learning (PBL) project, where they perform a self-assessment exercise of the patient care they provide in their clinic and formulate an improvement plan based on the results. At the conclusion of the Ambulatory Block, the Primary Care Chief Resident meets with the group to review their PBL results and the literature that supports the standard of care.
- While working in small groups, residents propose and implement a patient safety and quality improvement project, and present their results during the rotation.
Training in Procedural Skills and Practice Management
Through seminars residents have the opportunity to hone specific skills useful for a career in primary care and general internal medicine. In addition, exposure to the practical business of medicine is provided through a lecture series.
Residents can enhance their skills through subspecialty clinics or workshops to learn:
- Joint aspiration and injection
- Skin biopsy and suturing
- Management of strains and sprains
- Ultrasound guided procedures
Practice Management Seminars
- Getting ready to apply for a job: Early in the year, senior residents learn the proper timeline for applying for positions, updating their CV and using the internet and headhunters to begin the job search process.
- The job interview: Issues discussed include basic approach to the job interview, what to know before you go, key questions to ask during the discussion, and appropriate follow-up.
- Assessing a private practice: Residents need to be aware of many aspects of the practice when determining whether it will be a suitable setting for them. Among the many topics discussed are how the practice approaches patient care, triages phone calls, manages charts and documents, arranges call schedules and manages workload distribution among the physicians.
- Your first job contract: Lawyers join a group discussion to help residents in evaluating their first contract and understanding the key terms for their future practice.
- Office management: Sessions include information on patient medical insurance, billing, coding, interaction of office personnel and telephone medicine, among other topics.
Episodic Ambulatory Care Experiences
During their ambulatory time, residents rotate through our Faculty Practice Office (FPO), where they work alongside our general medicine faculty in a private practice setting. During their first year of training, residents rotate through the Emergency Room at UMMC and the Emergency Care Services (ECS) at the VA. They return to ECS in the 2nd and 3rd years, where they receive additional training in outpatient urgent care medicine and emergency medicine. The Emergency Room experience is described under the University of Maryland Medical Center.