Ambulatory Program - Internal Medicine Residency
Residents receive extensive training in ambulatory care through their continuity medical clinics and in subspecialty practices, walk-in clinics 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 our noon core curriculum and 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 - Academic GIM and X+Y Rotations
Residents immerse themselves in their a continuity medical clinic throughout their residency training. Clinic sites include University Health Center (UHC), the Primary Care Clinics at the VA, the Faculty Practice Office (FPO), and Mercy Medical Center. Our continuity clinics are a positive clinical and educational experience for the residents where they establish a 3-year relationship with their attendings, while ensuring a positive balance with their other clinical responsibilities. Based on an X+Y model, scheduling is different for interns and upper level residents.
- Interns have a 2-week fall and spring Academic General Internal Medicine (GIM) block where they attend their continuity clinics in the afternoons and have a variety of learning sessions in the morning. During the fall Academic GIM block, interns attend primary care conferences, sessions in simulation, ultrasound, literature in medicine, skills boosters and wellness. During their spring Academic GIM block, interns choose from GIM and subspecialty outpatient practices to meet their learning needs and career goals. Clustering continuity clinics into blocks allows interns to focus on their inpatient rotations and not attend clinic during MICU, CCU, night float and ER rotations. To maintain continuity with their patient panels, interns attend clinic 1/month during floor rotations and 1/week during electives.
- Second and third year residents attend continuity clinics in six 2-week blocks using an X+Y structure. The ambulatory Y blocks are strategically positioned to give residents flexibility for family and personal events or interviewing for fellowships. So we call our system -- FleX+Y. Consolidating continuity clinics into 2-weeks blocks allows residents to focus and build their ambulatory skills and patient panel. Residents attend their continuity clinic in the afternoons and choose outpatient electives during the mornings. These electives are in all the medical subspecialties and primary care. Morning sessions also include primary care conferences, sessions in simulation, ultrasound, literature in medicine, wellness, problem based learning and quality improvement projects.
Ambulatory Y Blocks
As noted above, interns complete two 2-week Academic GIM blocks and upper level residents complete six 2-week ambulatory Y blocks each year. Residents attend their continuity clinics during the afternoons and choose ambulatory electives for the morning sessions. The Primary Care Chief Resident works with each resident to individualize their morning sessions to meet their career needs -- whether they are deciding among various subspecialties or primary care, or solidifying their commitment to a particular field. For example, residents interested in cardiology elect clinics in advanced heart failure, general cardiology or electrophysiology. Those interested in oncology elect clinics in infectious diseases, medical oncology, hematology and infusion medicine. Residents interested in primary care elect clinics in women's health, orthopedics, rheumatology, dermatology and travel medicine, and attend private practices in the community to gain exposure to "real life" primary care and learn the business of medicine.
There are several required components in the Ambulatory Y Blocks include geriatrics, neurology, psychiatry, literature in medicine, primary care conferences and completion of practice based learning exercises and a longitudinal QI project, along with simulation and ultrasound curriculum.
- Residents are scheduled for simulation and ultrasound sessions to enhance these skills and build confidence in performing procedures and leading codes using ACLS.
- During Geriatrics, residents learn how a multidisciplinary team addresses the elderly patient's medical, psychological and social concerns.
- In the Neurology practices, residents evaluate and manage problems such as chronic seizure disorders, peripheral neuropathy, movement disorders and headaches.
- Residents participate in Psychiatry Seminars, where they discuss common outpatient psychiatric problems, such as depression and personality disorders.
- A very popular component of the Ambulatory Blocks is Literature in Medicine. Led by a faculty member, the residents read and discuss the works of authors and poets, reflecting on how the writings apply to the practice of medicine and the humanistic aspects of our profession. You can often find this group learning under the trees in the park across the street from the hospital. A wonderful wellness event!
- 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.
- Working in small groups, residents propose and implement a patient safety and quality improvement (PSQI) project that is continued longitudinally throughout their Y blocks.
- Through the primary care conferences, interns on their Academic GIM and residents on their Y blocks learn from senior residents and GIM faculty. The Yale curriculum provides a comprehensive review of topics helpful in the care of their continuity patients.
Various workshops are held throughout the year to help residents transition to their future career. These include workshops in interviewing skills, applying for a fellowship, creating your CV, business of medicine and sessions on specific careers such as subspecialties, hospital medicine, primary care and global health.
- Getting ready to apply for a fellowship or 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. Faculty review each CV and coach residents in the application process.
- The fellowship or job interview: Issues discussed include basic approach to the fellowship or job interview, what to know before you go, key questions to ask during the discussion, and appropriate follow-up.
- Assessing a private practice: Residents learn about various aspects of the practice, including how the practice approaches patient care, triages phone calls, and manages charts, documents, call schedules and workload 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: Residents learn these skills at their continuity clinic site including billing, coding, urgent care within a continuity practice, interaction of office personnel and telephone medicine.
Other Ambulatory Experiences
During their ambulatory time, second year residents rotate through our Faculty Practice Office (FPO), where they work alongside our general medicine faculty in a private practice setting. Interns rotate through the Emergency Room at UMMC and the Emergency Care Services (ECS) at the VA and 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.