Continuity Clinic Rotation

Rotation/Educational Purpose:

The majority of Internal Medicine is practiced in the outpatient setting and it is absolutely crucial that the resident develop outpatient skills. Further, residents must learn to provide continuity care to a set population of patients. This allows them to see the natural history of the chronic diseases and conditions cared for by internists. Continuity clinic also allows the resident to learn the tenets of preventative medicine and screening. Our continuity clinics provide the residents with expert mentorship, direct supervision, graded autonomy and the resources to enrich the direct clinical experiences. Residents are exposed to a diverse patient population in all three clinic sites.

Patient Care Goals and Objectives:

Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Residents are expected to:

PGY 1

1. Assess and manage diseases and disorders commonly encountered in an outpatient setting, through an understanding of epidemiology, pathophysiology and natural history of ambulatory diseases.

PGY 2 and 3

1. Assess and manage diseases and disorders commonly encountered in an outpatient setting, through an understanding of epidemiology, pathophysiology and natural history of ambulatory diseases.

Medical Knowledge Goals and Objectives:

Goal: 

PGY 1

PGY 2 and 3

Practice-Based Learning and Improvement Goals and Objectives:

Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.

Residents are expected to develop skills and habits to be able to:

PGY 1

1. Be involved in quality management as a regular educational and clinical activity.

PGY 2 and 3

1. Be involved in quality management as a regular educational and clinical activity.

Systems Based Practice Goals and Objectives:

Goal: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Residents are expected to:

PGY 1

1. Appreciate, recognize and address the biopsychosocial factors in wellness and disease.

2. Function effectively as a member of an interdisciplinary health care team.

3. Employ computers to facilitate ambulatory care.

4. Refer patients from inpatient services into continuity panel for primary care.

PGY 2 and 3

1. Appreciate, recognize and address the biopsychosocial factors in wellness and disease.

2. Function effectively as a member of an interdisciplinary health care team.

3. Employ computers to facilitate ambulatory care.

4. Present and discuss ambulatory topics at Ambulatory Grand Rounds three times weekly.

Professionalism Goals and Objectives:

Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Residents are expected to:

PGY 1

1. Develop skills that encourage ongoing personal and professional growth.

PGY 2 and 3

1. Develop skills that encourage ongoing personal and professional growth.

Interpersonal and Communication Skills Goals and Objectives:

Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.

Residents are expected to:

PGY 1

1. Develop effective interpersonal and communication skills.

2. Increase patient compliance with preventive health behavior and treatment regimens.

PGY 2 and 3

1. Develop effective interpersonal and communication skills.

2. Increase patient compliance with preventive health behavior and treatment regimens.

Teaching Methods:

Residents have continuity clinic each week throughout their residency except during Float, ER (PGY 1 year), and MICU (PGY 2 to 3 years) rotations. In addition, during month long UIM clinic rotations, the number of continuity clinics is increased to three times weekly to further garner a continuity experience. Residents learn by providing primary care to their patients. The majority of teaching in continuity clinic is case-based one on one teaching at the time of presentation. This teaching can include demonstration of history taking or examination skills, modeling communication, teaching screening and prevention, exploration of medical knowledge, or probing medical decision-making skills. Presentations can lead to brief teaching points or in-depth discussion of differential diagnosis and therapy.  Residents are expected to attend Monday, Wednesday, Thursday Ambulatory Grand Rounds where ambulatory topics pertinent to general medicine practice are discussed.

Mix of Diseases and Pathological Material:

Leading diagnoses include diabetes, hypertension, hyperlipidemia, coronary artery disease, CVAs, CHF, COPD, asthma, GERD, chronic renal insufficiency, dementia, and arthritis. Residents care for a diverse patient population with respect to age, ethnicity, and gender. The majority of the patients are older adults, but there are significant numbers of adolescent and young adult patients in some sites.

Patient Characteristics:

Residents care for a diverse patient population with respect to age, ethnicity, and gender. The majority of the patients are older adults, but there are significant numbers of adolescent and young adult patients in some sites.

Types of Clinical Encounters:

Each resident will evaluate new and return patients for acute or chronic problems. Residents  have first contact with all patients and are expected to develop a care plan for each patient encounter. Residents often refer patients from the inpatient service to their outpatient panel for primary care. Additionally, residents are expected to visit and participate in the care of their hospitalized patients. 

Procedures and Services:

Residents often have the opportunity to perform ambulatory procedures such as arthrocentesis, joint/soft tissue injections, Pap smear/pelvic examination, rectal examination and occasionally thyroid aspiration. All procedures are appropriately supervised by the attending physician. Interns and residents are expected to interpret all EKGs and chest x-rays performed on their patients. Further, residents perform urinalysis, wet preps, KOH examinations and other office lab tests.

Supervision:

All patients are presented to the attending physician. The attending physician directly supervises patient care and all procedures. The resident interacts with the entire interdisciplinary team, including the clinical pharmacists, the social worker, nurse case managers, diabetic educators, and dietitians.

Educational Resources to be Used and Reading Lists:

Each site has a wide selection of texts including Primary Care and comprehensive Internal Medicine texts. Computer based search engines are available in each clinic. Computer access to online texts and journal is available through the MUSC library web site. Up-To-Date is available on the VA computer system.

Method of Evaluation of Resident Competence:

Residents are evaluated every six months using the global evaluation form. The Mini-CEX will be administered in continuity clinic as well. The nursing staff evaluates the residents’ professionalism. Patient Care is assessed based on direct observation and complete review of all records. Medical Knowledge is assessed through direct questioning and observation. Interpersonal Skills and Communication is assessed by observation of interactions with patients and families. The attending physician evaluates Professionalism through direct interaction and observation of the resident. The nurses also evaluate resident professionalism. Systems-Based Practice is evaluated based on interactions with the primary team and the ability to provide medical care in the clinical setting. Practice-Based Learning is evaluated based on the ability to consult the literature and to improve their performance over time. Residents receive formative evaluation throughout the year.

The residents evaluate the clinics and the attending physicians through the E*Value system. The General Medicine Division reviews the evaluations and each attending anonymously receives his or her evaluations.