IM AMBULATORY CLINIC GOALS AND OBJECTIVES

Educational Goals and Objectives:

Goal of this experience is to help residents feel comfortable in the management of common ambulatory medical conditions. They will learn this by managing common medical problems under supervision of teaching clinical faculty by attending half day outpatient clinics every week during the month of rotation in General Internal Medicine, Medicine Subspecialties, Gynecology, Pain Clinic, Ophthalmology, Otolaryngology, Allergy and Immunology, Orthopedics / Sports Medicine, Psychiatry, Physical Medicine & Rehabilitation and Adolescent Medicine.

They will perform necessary outpatient minor surgical procedures as needed. They will learn to administer preventative care to improve quality of life and reduce morbidity and mortality in the patients they follow. They will educate their patient on health management. They will learn to adopt a model of primary care group practice and learn to cover each other’s patients effectively. They will continue to learn through practice based medicine, reading and preparing case materials as noted and relevant literature. This will be done under supervision and as they master these skills, they will transition to independent roles. They will learn practice management skills of billing (CPT coding) and ICD coding.

PGY 2 / PGY 3
Patient Care • Effectively interview ambulatory patients
• Effectively examine ambulatory patients
• Maintain focus and timeliness in the evaluation and management of ambulatory problems
• Understand and implement appropriate strategies for disease prevention and health promotion
• Develop strategies to efficiently evaluate and manage common ambulatory medical problems in certain subspecialties
• Gain confidence/skill in common ambulatory procedures (e.g. pelvic exams)
Medical Knowledge • Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of ambulatory patients
• Access and critically evaluate current medical information and scientific evidence relevant to ambulatory patient care
• Expand knowledge base in the following medical specialties as mentioned below:
   1. Allergy/Immunology (PGY 2)
   2. Adolescent Medicine (PGY 2)
   3. Sleep Medicine (PGY 2)
   4. Physical Medicine and Rehabilitation (PGY 3)
   5. Management of Pain (PGY 3)
   6. Geriatric Psychiatry (PGY 3)
   7. Otolaryngology (PGY 3)
   8. Medical Management in Orthopedics (PGY 3)
   9. Ophthalmology (PGY 3)
   10. Renal Transplant (PGY 3)
Practice-Based Learning and Improvement • Identify and acknowledge gaps in personal knowledge and skills in the care of ambulatory patients
• Develop real-time strategies for filling knowledge gaps that will benefit patients in a busy practice setting
Interpersonal and Communication Skills • Communicate effectively with patients and families across a broad range of socioeconomic and ethnic backgrounds
• Communicate effectively with physician colleagues and members of other health care professions to assure comprehensive patient care
Professionalism • Behave professionally toward patients, families, colleagues, and all members of the health care team
Systems-Based Practice • Understand and utilize the multidisciplinary resources necessary to care optimally for ambulatory patient care
• Collaborate with other members of the health care team to assure comprehensive ambulatory patient care
• Use evidence-based, cost-conscious strategies in the care of ambulatory patients
• Begin to understand the business aspects of practice management in a variety of settings

INTERNAL MEDICINE RESIDENTS MEDICAL KNOWLEDGE OBJECTIVES IN EACH MEDICINE SPECIALTY DURING THE AMBULATORY ROTATION:

ADOLESCENT AMBULATORY ROTATION

1. Understand normal adolescent behavior, growth, development and physiology and recognize deviations from the norm
    Describe the pathophysiology, evaluation and management of variations in growth patterns and pubertal changes
2. Understand pathophysiology and manage the following common conditions in adolescents:
   a. Behavioral/Psychiatric – mild cases of substance abuse, migraines, ADHD, depression, suicidal/homicidal ideation, anxiety, conduct disorder
   b. CV – risk for CV disease in adulthood –hyperlipidemia, hypertension
   c. Derm – acne, acanthosis nigricans, body art including piercings and tattoos, hydradenitis suppurativa
   d. Endo – galactorrhea, male gyncomastia, hirsuitism, polycystic ovarian syndrome, thyroid disease
   e. GI – Gastroesophageal reflux disease
   f. GU – varicocele, epididymitis, testicular torsion, hydrocele
   g. GYN – dysmenorrheal, premenstrual syndrome, dysfunctional uterine bleeding, amenorrhea, STIs, PID, pregnancy diagnosis, breast mass, PAP smear abnormalities, endometriosis
   h. Musculoskeletal/Sports Medicine – scoliosis, Osgood Schlatter, overuse syndromes
   i. Nutritional – eating disorders
   j. Pulmonary – asthma

ALLERGY AND IMMUNOLOGY AMBULATORY ROTATION

1. Asthma diagnosis, pathophysiology and treatment
2. Rhinitis, classification, diagnosis and treatment
3. Atopic dermatitis, diagnosis and treatment
4. Anaphylaxis, diagnosis and treatment
5. Drug reactions, diagnosis and treatment
6. Food reactions, diagnosis and treatment
7. Uticaria, diagnosis and treatment
8. Initial evaluation of immunodeficiency states
9. Allergy skin testing
10. Allergen immunotherapy
11. Status asthmaticus, diagnosis and treatment
12. Care of patient with asthma and allergic rhinitis during pregnancy
13. Sinusitis
14. Allergic contact dermatitis, diagnosis and treatment
15. Stinging insect reactions, diagnosis and treatment
16. Clinical immunology, including components of the immune system and immunological reactions in the more common immunodeficiency states.

GERIATRIC PSYCHIATRY AMBULATORY ROTATION

1. Differential diagnosis and evaluation of dementia
2. Evaluation and risks of polypharmacy in the elderly population

Importance of evaluation social history and how it relates to medical disorders in the elderly population

GYNECOLOGY AMBULATORY ROTATION

Although the gynecologist is frequently the primary care physician for women in the 2nd decade of life, the internist is frequently an alternative source of medical aspects of gynecologic management. In subsequent decades, the general internist becomes the major source of care for the American female. It is intended that the medical resident will prepare for this experience by reading the basic literature based on this outline. Performance of procedures noted among the objectives listed below is an essential part of the rotation. The reading associated with this exercise is organized with the ABIM examination in mind and is therefore somewhat broad.

The resident will be able to describe and carry out the following:

1. Vulvovaginitis: diagnosis and management of
   a. Candida
   b. Trichomonas
   c. Hemophilus Vaginalis Vaginitis
   d. Atrophic Vaginitis
   e. Herpes Genitalis
2. Pelvic Inflammatory Disease
   a. Physical signs
   b. Appropriate means for identifying organisms
   c. Proper selection of therapy
3. Dysfunctional Uterine Bleeding
   a. Diagnosis
   b. Therapy
4. Sexual Dysfunction in Females
   a. Diagnostic approach – Pertinent history and examination.
   b. Decision about referral to Gynecologist.
5. Contraception for Women
   a. Premarital examination and counseling.
   b. Contraception for women; selection and implementation of
6. Post Coital Conception Control
7. Prenatal Care
8. Osteporosis Management

HEMATOLOGY AMBULATORY ROTATION

At the end of this rotation the resident will be able to:
1. Discuss the work up of anemia
2. Evaluate a peripheral smear
3. Discuss the indications for a bone marrow biopsy
4. Discuss the indications for various blood products
5. Discuss the pathophysiology, course and treatment of the various leukemias.

OPHTHALMOLOGY AMBULATORY ROTATION

1. Learn the differential diagnosis of red eye
2. Learn about the four leading causes of blindness after age 50 (cataracts, glaucoma, age-related macular degeneration, and diabetic retinopathy).
3. Know how to check for relative afferent papillary defect
4. Feel comfortable doing a dilated fundus exam.

ORTHOPEDIC AMBULATORY ROTATION

1. Gain comfort in the various joint exams.
2. Learn the indications for surgical consultation in evaluating back, shoulder, hip and knee pain.
3. Learn the indications for various pre-operative work ups (stress tests, etc.)

OTOLARYGOLOGY AMBULATORY ROTATION

1. Surgical management of sleep apnea
2. Diagnosis and treatment of chronic sinusitis
3. Diagnostic approach to vertigo
4. Learn indications, performance and interpretation of audiology evaluations for hearing loss
5. Learn indications, performance and interpretation of speech/swallow evaluations

PHYSICAL MEDICINE & REHABILITATION AMBULATORY ROTATION

During the GIM ambulatory rotation, the resident will have the opportunity to become familiar with important aspects of rehabilitative care. While the resident will be working with the rehabilitation team as a medical consultant on inpatient rehab patients, this segment of the rotation places particular emphasis on ambulatory rehabilitative care.

At the end of the rotation, the resident will be able to:
1. Identify those conditions that can cause peripheral neuropathy.
2. Recognize the potential benefits of epidural steroid injections.
3. Describe the most common causes of spinal cord injury.
4. List the commonly accepted indications and contraindications for joint replacement.
5. Discuss the common types of traumatic brain injury.
6. Recall the common diagnoses and reasons for ordering an electrodiagnostic study.

RENAL TRANSPLANT AMBULATORY ROTATION

1. Learn the indications for renal transplantation.
2. Learn the use of anti-rejection medications.
3. Learn the common causes of infection in the transplanted patient.

SLEEP LAB AMBULATORY ROTATION

1. Learn the typical course and treatment of Obstructive Sleep Apnea.
2. Learn how a sleep lab functions.
3. Learn the indications and interpretation of a sleep study.

Teaching Methods:

1. Direct patient care
2. Directly supervised procedures
3. Faculty supervision
4. Core curriculum
5. Observed clinical examination skills
6. Reading materials and literature search

Assessment Methods – Competency Score Card:

Medical Knowledge

1. Monthly test
2. New Innovation evaluations
Patient Care
1. Procedures
2. Mini-CEX
3. New Innovation evaluations
Practice-Based Learning
1. New Innovation evaluations
2. Consultation/Literature search (PGY 2/3)
System-Based Learning
1. New Innovation evaluations
Professionalism
1. Medical record completion
2. New Innovation evaluations
3. Dictation completeness
Communications
1. 360 evaluations
2. New Innovation evaluations
3. Transition of care (hand-off)

Educational Resources:

1. Ambulatory Medicine, Barker et al
2. Harrison’s Principles of Internal Medicine
3. Up-To-Date
4. Reading material provided by faculty
5. Low Back Pain for the Primary Care Physician by Andrew Cole
6. Physical Medicine and Rehabilitation by Randall Brandom
7. Essentials of Musculoskeletal Care by Robert Snyder
8. Physical Examination of the Spine and Extremities by Stanley Hoppenfeld
9. Massachusetts Eye and Ear Infirmary
10. Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed. (available online via MD Consult)

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