Ambulatory Medicine Rotation Educational Goals & Objectives

The Ambulatory Medicine rotation will provide the resident with an opportunity to become skilled in the prevention, evaluation, and management of acute and chronic medical conditions commonly seen in the outpatient setting. Residents will rotate through the Ambulatory Clinic weekly throughout their 3 years in the program. They will grow their own patient panel, with patients from adolescence through geriatrics. The focus will be on the doctor-patient relationship, continuity of care, and the effective delivery of primary care. Residents will gain exposure to a broad spectrum of medical conditions, ranging from core internal medicine issues to conditions
requiring knowledge of allergy and immunology, nutrition, ophthalmology, orthopedics, otolaryngology, preventative medicine, and psychiatry as they pertain to the general care of outpatients in the community. They will also learn about billing and coding, insurance coverage, and other concepts pertinent to systems-based practice in the outpatient setting. Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

All residents must be able to provide compassionate, culturally sensitive care for their
clinic patients.

• PGY2s should seek directed and appropriate specialty consultation when necessary to further patient care.
• PGY3s should be able to coordinate input from multiple consultants and manage conflicting recommendations.

II. Residents will demonstrate the ability to take a complete medical history and
incorporate information from the electronic medical record.

• PGY1s should be able to differentiate between stable and unstable symptoms and elicit risk factors for the development of chronic disease.
• PGY2s will independently obtain the above information and identify barriers to patient compliance and care.
• PGY3s should be able to independently obtain the above details for patients with complex medical histories and multiple comorbid conditions.

III. Residents should be able to perform a physical exam appropriately focused on the patient’s presenting complaint.

• PGY1s should become competent in routine breast, pelvic, bimanual exams, and thyroid exams.
• PGY2s should be able to focus on and characterize abnormal exam findings pertinent to the presenting complaint.
• PGY3s should be able to independently perform a complete exam and understand the sensitivity and specificity of physical findings.

IV. Residents will understand the indications, contraindications, complications,
limitations, and interpretation of the following procedures, and become competent in
their safe and effective use:

• PGY1s: incision and drainage of skin abscesses, punch biopsy, cryotherapy, pelvic examination and PAP smear, suture removal, wet mount exam.
• PGY2s: common joint and trigger point injections.
• PGY3s may elect to develop competence in other specialty procedures with faculty guidance based on their area of practice interest.
• All residents interested in POCUS can elect to pursue competency certification during residency.

Medical Knowledge

I. PGY1s will become skilled in the timely triage of and approach to acute changes in
health status, including:

• Abdominal pain
• Acid base disorders
• Cough
• Chest pain
• Electrolyte abnormalities
• Hypotension
• Mental status change
• Oliguria
• Palpitations
• Rash
• Sepsis
• Shortness of breath

PGY2s should be able to incorporate presenting information into the context of past
medical history and a risk assessment to generate a differential diagnosis and a more
thorough plan of care.
PGY3s should be able to understand statistical concepts such as pretest probability,
the number needed to treat, etc., and their effect on diagnostic workup and treatment.
II. PGY2s will also develop an understanding of the pathophysiology, clinical
presentation, natural history, and therapy for the following conditions:

• Allergic rhinitis
• Anemia
• Anxiety
• Asthma
• Atrial fibrillation
• Benign prostatic hypertrophy
• Bronchitis and/or pneumonia
• Chronic kidney disease
• Chronic liver disease
• Chronic pain
• Conjunctivitis
• Coronary artery disease
• COPD
• Congestive heart failure
• Depression
• Diabetes mellitus type II
• GERD and dyspepsia
• Headache
• Hyperlipidemia
• Hypertension
• Hypothyroidism
• Low back pain
• Obesity
• Osteoarthritis
• Osteoporosis
• Sinusitis

III. PGY3s will develop an understanding of the pathophysiology, clinical presentation,
and targeted therapy for the above conditions, with attention to differences in patient
populations where appropriate.
IV. Residents will understand the effective use and interpretation of the following tools:

• Alcohol Single-Question Screener
• Breast Cancer Risk Assessment Tool (National Cancer Institute)
• Brief Patient Health Questionnaire (PHQ-9) and Depression Inventory
• Cockroft Gault and MDRD calculators
• ACC/AHA Coronary Risk Calculator
• FRAX (WHO Fracture Risk Assessment Tool)
• MELD score
• Montreal Cognitive Assessment (MoCA)

V. Residents will become familiar with frequently used complementary and alternative
medicine treatments for common outpatient problems.
VI. Residents will be aware of USPTF guidelines for health maintenance and be able to
counsel patients on the following issues pertaining to healthcare maintenance:

• Age-appropriate cancer screening
• Contraception and safe sex
• Exercise and prevention of cardiovascular disease
• Nutrition and weight loss
• Smoking cessation
• Substance abuse
• Vaccination

VII. Residents will understand indications for ordering and interpretation of results from

laboratory and imaging studies relevant to the diagnosis and treatment above conditions.

Practice-Based Learning and Improvement

I. All residents should be able to access current clinical practice guidelines from
USPTF, ADA, JNC, NCEP, and other sources to apply evidence-based strategies to patient care.

II. PGY1s will learn to use the electronic medical record effectively and understand the
definition of meaningful use.

III. PGY2s should develop skills in evaluating studies in published literature, through Journal Club and independent study.

IV. All residents should learn to function as part of a team, including the primary care
physician, nurse, midlevel provider, medical assistant, and social worker to optimize
patient care, with PGY3s taking a leadership role.

V. All residents should respond with positive changes to feedback from members of the health care team.

Interpersonal and Communication Skills

I. PGY1s must demonstrate organized and articulate electronic and verbal
communication skills that build rapport with patients and families, convey
information to other health care professionals, and provide timely documentation in
the chart.

II. PGY2s must also develop interpersonal skills that facilitate collaboration with
patients, educate patients, and where appropriate, promote behavioral change.

III. PGY3s should demonstrate leadership skills to build consensus and coordinate a
a multidisciplinary approach to patient care.

IV. PGY3s must be able to elicit information or agreement in situations with complex
social dynamics, for example, identifying the power of attorney or surrogate decision
maker, and resolving conflict among family members with disparate wishes.

Professionalism

I. All residents must demonstrate a strong commitment to carrying out professional
responsibilities as reflected in their conduct, ethical behavior, attire, interactions with
colleagues and community, and devotion to patient care.

II. All residents should be able to educate patients and their families in a manner
respectful of gender, age, culture, race, religion, disabilities, national origin,
socioeconomic status, and sexual orientation on choices regarding their care.

III. PGY2s should be able to use time efficiently in the clinic to see patients and chart
information.

IV. PGY3s should be able to provide constructive criticism and feedback to more junior
members of the team.

Systems-Based Practice

I. PGY1s must have a basic understanding that their diagnostic and treatment decisions involve cost and risk and affect the quality of care.

II. PGY2s must be able to discuss alternative care strategies, taking into account the
social, economic, and psychological factors that affect patient health and use of
resources.

III. PGY2s should understand the impact of insurance status on patient access to care and be aware of the availability of caseworkers, counseling services, and other community resources to maximize care.

IV. PGY3s must demonstrate an awareness of and responsiveness to established quality measures, risk management strategies, and cost of care within our system.

V. Residents must be aware of current quality issues in ambulatory care, such as cancer
screening.

VI. Residents will become familiar with issues pertinent to the practice of medicine, such as coding and reimbursement, liability, and the costs and legal issues involved in
running a practice.

Teaching Methods

I. Supervised patient care in the clinic

• Residents will initially be directly observed with patients, to facilitate the acquisition of excellent history-taking, physical exam, and procedural skills.
• As residents become more proficient, they will interact independently with patients and present cases to faculty.
  • For PGY1s, the initial emphasis will be on diagnosis and basic management.
  • For more senior residents, the focus will be on medical decision-making, and residents will work with supervising physicians to finalize a care plan.

II. Conferences

• Specialty-specific didactics
• Discussion of weekly clinic topics

III. Independent study

• Journal and textbook reading
  • Annals of Internal Medicine - In the Clinic series
  • MKSAP
• Additional reading as recommended by the Attending physician
• Online educational resources
  • ACP Caring with Compassion
  • NEJM Case Studies in Social Medicine
  • Resources for pain management and addiction
    • CDC: Changes in Opioid Prescribing Practices and Checklist for Prescribing Opioids for Chronic Pain
    • ACP Chronic Pain and Safe Opioid Prescribing
    • California Bridge Program
    • NIDA Opioid
  • Social Determinants of Health Screening Tools
    • National Association of Community Health Centers’ Protocol for
      Responding to and Assessing Patients’ Assets, Risks, and
    • Experiences tool
    • AAFP The EveryONE Project
    • Centers for Medicare & Medicaid Services Accountable Health
    • Communities Health-Related Social Needs Screening Tool
  • The Stanford 25
  • Trans and gender-diverse resources
    • UCSF Center of Excellence for Transgender Health
    • Stanford Medicine Health Across the Gender Spectrum
• US Prevention Services Task Force Recommendation Statement on
  Screening For Hepatitis C Virus Infection in Adolescents and Adults
• Up To Date
• Clinical Key

Evaluation

I. Case and procedure logs
II. Mini-CEX bedside evaluation tool – residents must complete a minimum number in
PGY1 and PGY2 year in the venue of their choice. Additional direct observation
during clinical activities is strongly encouraged.
III. Continuity Clinic Evaluation – four times per year
IV. 360 Evaluation – twice per year
V. Attending written evaluation of resident at the end of the year, based on observations and chart review.

Rotation Structure

I. Residents should be in the clinic during their scheduled times.

• Residents are the primary care providers for their patients. Residents will be involved in the discussion of patient presentation, generation of a differential diagnosis, development of a treatment plan, and patient follow-up. In addition, residents will be involved in surgical procedures as appropriate.
• Case-based learning is the most effective. Nightly reading/study should be based on patients seen during the day.
• When doing outpatient internal medicine consults, the resident should understand the question asked and provide a concise answer.

II. Residents may be asked to do focused literature searches or presentations for the
attending or other learners during the clinic.
III. Residents will be required to do one quality improvement project over their 3 years
under the supervision of an attending mentor. The project will be shaped by the
resident’s interests but will require applying principles of quality improvement to
their own medical practice.
IV. Call and weekend responsibilities TBD by the attending physician.

• Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.

V. Residents have specialty-specific didactics and should be excused in a timely fashion
to attend.