Ambulatory Care Center

Continuity Clinics at the Ambulatory Care Center

Overview  ( return )

All Internal Medicine programs must provide adequate continuity experience for all residents to allow them the opportunity to develop an understanding of and appreciation for the longitudinal nature of general medicine patient care.  The resident continuity clinic is a required, longitudinal experience, which constitutes the gateway to outpatient care.  The role of the primary care physician in this ever-changing health care system is a pivotal one in the prevention of disease and care of chronic illnesses. This clinic allows the resident the opportunity to experience a long  term relationship with a panel of patients which emulates the practice of general medicine and is designed to prepare the resident for a career in medicine, whether one enters general practice or an academic sub-specialty.

All residents must have weekly half-day clinics scheduled for their continuity patients; interruptions in this experience are only allowed during vacations, emergency department, critical care rotations and away electives (other cities or oversease). Only during rotations with an overnight call schedule the usual clinic day will be cancelled  and a 'Pre-call clinic' will be scheduled on the day immediately before the call. It is the responsibility of the intern/resident to be aware of these schedule changes, to apropriately guide patients through the process of scheduling follow up appointments. The periods of interruption may not exceed two consecutive months at any time.

The continuity experience should emphasize physical and emotional growth and development, health promotion/disease prevention, management of chronic and acute medical conditions, as well as social and environmental issues as they affect the patient.  The patient population should provide adequate variety to meet the educational objectives.  Althought patients are scheduled on a first-call first-served basis, residents are encourage to request follow up appointments for their own continuity patients, and are entitled to include in their panel patients cared for at the inpatient rotations with due aproval of the clinic preceptor. This continuity experience must receive priority over other responsibilities.

The ACGME resident volume/clinic session expectations:

• PGY-1: "The number of patients seen by a first-year resident, when averaged over the year, must not be less than 3 or greater than 5 per scheduled 1/2-day session."
• PGY-2: "The number of patients seen by a second-year resident, when averaged over the year, must not be less than 4 or greater than 6 per scheduled 1/2-day session."
• PGY-3: "The number of patients seen by a third-year resident, when averaged over the year, must not be less than 4 per scheduled 1/2-day session."

In addition to direct patient care, interns and residents are required to attend and participate in weekly pre-clinic educational conference.  The curriculum is problem-based; apropriate literature will be sent via email and posted on this website the week prior to clinic.

Direct supervision is provided by faculty from the Division of General Medicine at the Medical Faculty Associates. Interns are assigned to a preceptor at the beginning of the year and they stay in the same preceptor group for the remainder of their residency. The preceptor devotes their time exclusively to precepting during resident clinic time and maintains a 4 to 1 resident to faculty ratio. The attending is actively involved in direct patient care and other competing responsibilities will not compromise their availability for supervision and consultation.

Goals and Expectations  ( return )

Our primary mission is to help our residents attain the necessary skills for diagnosing, treating and preventing disease in the outpatient setting. In addition, we have used our electronic medical record system in innovative ways to build the continuity of the resident-patient relationship, which fosters mutual trust and understanding.

Residents are expected to demonstrate the ability to provide compassionate, efficacious and efficient patient care to patients in the ambulatory setting with both acute and chronic conditions.

Residents will review the principles of epidemiology, pathophysiology, therapeutics, and prevention in the management a diverse set of illnesses. They will be expected to demonstrate experience in retrieving and critically reviewing the medical literature and apply concepts of clinical epidemiology and statistics.

Residents are expected to demonstrate willingness to continuous assess and improve their ambulatory knowledge base and clinical practice. They will learn the practice of evidence based medicine enabling the them to make rational clinical decisions, individualized to the needs of their patients.

Residents will learn to appropriately access the services of the multi-disciplinary team members for the care of their patients (social workers, nurses, medical assistants, patient reps, home visit nurses, physical therapist, nutritionist, interpretors). Residents will be expected to demonstrate an understanding of, and a willingness to help improve the various ambulatory resources available to our patients. Residents will become familiar with the working of an office practice, including scheduling/billing concepts, telephone medicine, preoperative evaluation, consultation and walk-in care.

Just like a primary care physician in real life setting, residents are expected to provide the necessary follow-up care by tracking labs, notifying their patients of results and answering messages in a timely fashion. Our excellent Electronic Medical Record, "Touchworks" facilitates this function very well. Access to Touchworks is available at all the satellite hospitals.

FAQs Regarding Clinics Schedules  ( return )

1. Who makes the clinic schedules?

The chief residents design the blocks and day-to-day schedules. Anne Lesburg ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ) will be in charge of clinic schedules this year. Schedules are 'finalized' in 3-4 month increments and appropriate notice will be given when final schedules are posted.

2. Where can I check my schedule?

Schedules will be posted in AMION. Clinic cancellations and pre-call clinics are posted in this website under 'Schedules'. A confirmation email will be sent each time a partial schedule is finalized. We strongly encourage you to check these schedules and notify the chiefs about any potential conflict. You can also access your schedule through TouchWorks: if you have patients assigned to you for a particular day, that means your schedule is opened! Contact the chiefs if this is in conflict with your block schedule.

3. What's the policy regarding schedule changes and clinic switches? Am I allowed to call 'backup' or have a coleague cover for me if I need to have the day off?

Once schedules are final, no changes are allowed except for emergencies. Any last-minutes change to the final schedule will be considered on a case-by-case basis and ultimately approved by Dr. El-Bayoumi. Continuity Cinic is a mandatory longitudinal experience and residents are expected to be available for their patients in a dependable manner. Clinic switches generate confusion, defeats the purpose of continuity and interrupt continuing medical education from your assigned preceptor. Therefore, 'switches' are not allowed under any circumstance. Cross-coverage will not be provided for failure to comply with clinic schedules; patients will be redistributed among the housestaff present in clinic that day.

4. What if I'm sick or can't go to work for a family/personal emergency?

We will call your patients if your clinic is cancelled, but be aware - some patients do not have telephones (or have invalid numbers) and will come to clinic anyway. We will always try to accommodate these patients by having one of the clinic providers see them to address acute issues that same day. Patients who do show up will be redistributed among the housestaff present in clinic that day.

5. What time am I expected to be at the Ambulatory Care Center for my clinic day?

You are expected to be at the Ambulatory Care Center no later than 1:10 to begin the didactic session. Didactics should begin promptly at 1:10 to avoid delaying patient care activities. If you are rotating away from GWUH (at Fairfax, the VA or the NIH), please make the necessary arrangements to leave your site early, since this is not a good reason to miss didactics.

6. How do I fit in a rapid follow up visit for a patient I have just discharged from the hospital?

Send an 'admin' task to your general internal medicine team in TouchWorks stating name and medical record of your patient; make sure you include a note clarifying that the appointment is a 'Hospital Follow Up', and request for a confirmation of the appointment. If you need an immediate confirmation, you can call (202) 741 2222 and make the appointment yourself.

7. What if I'm fully booked with old and new patients?

Whether you need to book a hospital follow up or a regular follow up visit for one of your patients in clinic, there are several strategies you can consider. You can arrange a follow up visit with other residents in your same clinic day, preferably one with whom you share preceptors. If you know your schedule and your panel well, you can also consider 'overbooking' your patients. If you expect a particularly slow day or you suspect that one of your patients may not show-up, you can fit in your patient in between slots. Always task your clinic preceptor through TouchWorks for advice.

8. What if there is a mistake in my schedule?

Mistakes can happen with over 100 providers in clinic. The more proactive you are about checking your schedule in advance, and helping to clarify mistakes, the better for everyone, including your patients.

Clinic Day Didactics  ( return )

Each clinic day, the precepting faculty convenes a 20 minute pre-clinic didactic session. The well designed and widely used "Yale Office-based Medicine Curriculum" serve as the basis for the weekly pre-clinic conference that takes place prior to residents seeing their patients in continuity clinic, from 1:10 pm through 1:30. Interns and residents are expected to read the cases and key reference materials prior to coming to the 20-minute conference. The groups are small (including only residents and faculty who have clinic that day), which facilitate active discussion and personalized education.

"The Yale Office-based Medicine curriculum is a literature-based curriculum that covers a wide span of primary care topics in internal medicine. The curriculum serves to provide an evidence-based approach for what we clinically practice and supplement practical experience with a didactic foundation, particularly in the case of unusual conditions a resident might encounter only rarely, and provide updates when new developments occur in therapy or standards of care."

" The cornerstones of this curriculum are realistic challenging cases and related questions which emphasize practical aspects of diagnosis or management. These exercises prompt not only information recall but also higher order cognitive skills, such as solving problems, evaluating new information, and making judgments. Twice a year, each resident receives a six-month syllabus of cases with related questions, and one or more high quality, peer-reviewed articles. Topics are selected by faculty with resident input and range from "bread and butter" primary care areas such as diabetes, asthma, and prevention to specialty areas, such as orthopedics, rheumatology, and dermatology. Each semester also includes chapters relevant to current practice, including such topics as coding, psychosocial medicine, or economic aspects of medicine, as well as recent therapeutic advances. Over three years of residency, residents will be exposed to a compendium of approximately 150 different topics as part of the rotating syllabus."

Evidence Based Medicine Case Presentation  ( return )

The first week of each month we make a parenthesis in the "Yale Office-based Medicine Curriculum" to hear presentations by the clinic residents. Each intern/resident is expected to prepare a presentation at least once every year; a sign in sheet is available in the work room at all times. We encourage interns/residents to sign up early!

The presentation should last no longer than 20 minutes. A desktop computer and a projector are available if needed. Ideally, the presentation should be problem-based, centered in a clinically relevant question that came up from clinic experience.  The presenter should guide the audience through a brief literature search, encourage open discussion and conclude with a summary of valuable teaching points. This activity will be evaluated by the precepting faculty.

You can check the scheduled presentations here.

Competency-based Curriculum  ( return )

A complete description of our core rotations' Competency-based Curriculums can be found somewhere else. These are the Continuity Clinic's Competency-based learning objectives and assessment methodologies for all levels of training.