VA Primary Care/Urgent Care

Educational Purpose:

The VAPC block ambulatory rotation is intended to give medical residents the experience of working with general medicine patients in an ambulatory care setting. It is designed to develop the clinical skills required by a general internist when evaluating and managing acute and chronic medical problems in the office setting. The rotation provides the residents the opportunity to practice in an interdisciplinary clinic setting and to spend some time in VA Urgent Care.

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. To enhance the residents’ history taking and physical diagnosis skills.
2. To develop differential diagnoses and formulate a treatment plan in an outpatient setting.
3. To manage the outpatient illnesses which are commonly cared for by the general internist.
4. To develop expertise in caring for outpatients with hypertension, diabetes, hyperlipidemia, coronary artery disease and COPD.
5. To learn to manage acute medical problems in the Urgent Care setting.

PGY 2 and 3

1. To enhance the residents’ history taking and physical diagnosis skills.
2. To develop differential diagnoses and formulate a treatment plan in an outpatient setting.
3. To manage the outpatient illnesses which are commonly cared for by the general internist.
4. To develop expertise in caring for outpatients with hypertension, diabetes, hyperlipidemia, coronary artery disease and obesity.
5. To enhance the residents’ ability to care for the older adult population.
6. To recognize the unique challenges associated with caring for a medically underserved population.

Medical Knowledge Goals and Objectives:

Goal: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.

Residents are expected to:

PGY 1

1. To develop differential diagnoses and formulate a treatment plan in an outpatient setting.
2. To learn to manage acute medical problems in the Urgent Care setting.

PGY 2 and 3

1. To develop differential diagnoses and formulate a treatment plan in an outpatient setting.

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 life long learning.

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

PGY 1

1. To effectively work with an interdisciplinary team in the outpatient setting.

PGY 2 and 3

1. To effectively work with an interdisciplinary team in the outpatient setting.
2. To supervise medical interns as well as medical students on the ambulatory rotation.

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. To understand the indications/need for appropriate outpatient subspecialty consultation.
2. To effectively work with an interdisciplinary team in the outpatient setting.

PGY 2 and 3

1. To understand the indications/need for appropriate outpatient subspecialty consultation.
2. To effectively work with an interdisciplinary team in the outpatient setting.
3. To supervise medical interns as well as medical students on the ambulatory rotation.

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 demonstrate:

PGY 1

PGY 2 and 3

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. To enhance the residents’ history taking and physical diagnosis skills.
2. To demonstrate interpersonal skills and to communicate effectively with patients and families.

PGY 2 and 3

1. To enhance the residents’ history taking and physical diagnosis skills.
2. To demonstrate interpersonal skills and to communicate effectively with patients and families.

Teaching Methods:

The majority of teaching on the VAPC/VAUC rotation is case-based one on one teaching at the time of presentation. Residents and students present patients for in-depth discussion of differential diagnosis and therapy. Ambulatory morning report is held once weekly prior to the start of clinic. The doctor-patient communication conference is held weekly prior to the onset of clinic.

Mix of Diseases and Pathological Material:

Residents care for patients with a wide variety of clinical entities including diabetes, hypertension, hyperlipidemia, coronary artery disease, CVAs, CHF, COPD, asthma, GERD, chronic renal insufficiency, dementia, arthritis, UTIs, bronchitis, and many others. Urgent Care patients share many of the same diagnoses, but they have more acute complaints. Residents care for a diverse patient population with respect to age and ethnicity. Tobacco, alcohol, and other substance abuse is quite prevalent in this population.

Patient Characteristics:

Residents care for a diverse patient population with respect to age, ethnicity, and gender. The majority of the patients are older adults; however significant numbers of adolescent and younger adults are also represented

Types of Clinical Encounters:

The rotation takes place in the VAPC and VA Urgent Care. Residents evaluate new patients, routine return visits, and acute sick visits. The resident often must decide whether to treat in the outpatient setting or to admit to the hospital. Preventative medicine is stressed with each encounter.

Procedures and Services:

Residents often have the opportunity to perform many procedures on the VAPC/Urgent Care rotation. Common procedures include arthrocentesis, joint injections, and paracentesis. Central Venous catheter placement is rarely performed in this setting as well. Interns and residents are expected to interpret all EKGs and chest x-rays performed on their patients.

Supervision:

All procedures are appropriately supervised by the attending physician. There are approximately four upper level residents and two interns assigned to the VAPC rotation each month. These residents independently evaluate patients as noted above. Interns have a similar role, though they are more carefully supervised. All patients are then presented to the attending physician. The attending physician directly supervises patient care and all procedures. As the resident’s skills advance, the attending physician may not see each patient with the resident. Third year medical students and PA students are also assigned to the VAPC each month and the resident actively participates in educating and supervising the students. The resident interacts with the entire interdisciplinary team including the clinical pharmacists, the psychiatrist, the social worker, nurse case managers, nurse practitioners, and physician assistants.

Educational Resources to be Used and Reading Lists:

The VAPC has a wide selection of texts including Primary Care, Office Orthopedic, Dermatology, Psychiatry, Ophthalmology, and office Gynecology texts. Computer based search engines are available in the clinic and residents often search the literature on the VAPC rotation.

Method of Evaluation of Resident Competence:

Residents are evaluated using the global evaluation form. The Mini-CEX will be administered on this service as well. Patient Care is assessed based on direct observation and complete review of all records. Medical Knowledge is assessed through direct questioning, observation, and morning report participation. Interpersonal Skills and Communication is assessed by observation of interactions with patients and families. Role playing and trigger tapes are used in the doctor-patient communication sessions. The attending physician evaluates Professionalism through direct interaction and observation of the resident. Systems-Based Practice is evaluated based on interactions with the interdisciplinary team and their ability to access resources in caring for underserved patients. Practice-Based Learning is evaluated based on the ability to consult the literature and to improve their performance throughout the rotation. Residents receive formative evaluation throughout the month.

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