Ambulatory Curriculum Design and Delivery for Internal Medicine Residents

Abstract

This chapter guides ambulatory educators through the key educational principles, components, and steps needed for a robust ambulatory curriculum with a longitudinal design and a diverse delivery mechanism. Ambulatory medical education for residents is structured into three major curricula designs—ambulatory block rotations, longitudinal continuity clinics, and ambulatory long blocks. Embedded into these curricular designs is a core curricular thread comprised of high-yield ambulatory topics and delivered through various teaching pedagogies. Highlighted in this chapter are specific formal instructional strategies as well as resident-directed learning modalities. The chapter concludes with a step-by-step guide of the essential elements in developing an ambulatory curriculum. Sample implementation tools provide deliverables for educators to utilize in their own ambulatory teaching environment. These include needs assessment tools, mini-CEX forms, and a goal and objective template for resident continuity clinics.

Appendices

Appendix 1: A General Needs Assessment of Ambulatory Medicine Curriculum

Problem identification—What is the current approach? Barriers to implementation?	Ideal approach?	Goals and objectives	Resources needed for implementation?
.	.	.	.

Appendix 2: Targeted Needs Assessment of Learners

Key learners	Impact of curriculum	Relevant info needed from learners	Methods for learner needs assessment	Resources needed for implementation
.	.	.	.	.

Appendix 3: Example Goals and Objectives

Internal Medicine Residency Training Program

Resident Continuity Clinics

Resident Clinic Director: ____________

Rotation description: The continuity clinic rotation teaches residents to care for a longitudinal panel of primary care patients over their 3-year residency. In their primary care continuity clinics, residents will manage patients with a mix of acute care issues and chronic medical conditions, including but not limited to diabetes, hypertension, coronary artery disease, and COPD. Residents will also perform office-based procedures under the supervision of a clinic attending.

Principal Educational Goals by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME competencies in the tables below. The first column of the table lists the goals; the second column maps the goals to the reporting milestones competencies; the third column lists the most relevant learning activities for that goal; and the fourth column indicates the correlating evaluation methods for that goal.

PGY-1/2/3 (Goals Are for All Levels Unless Indicated)

Principal educational goals	Milestones competency	Learning activities	Evaluation methods
A. Patient care
Ability to take a complete medical history and perform a careful and accurate physical examination	PC1	DPC	FE, MC, CEX, SPE
Ability to write or dictate concise, accurate, and informative histories, physical examinations, and progress notes	PC1, ICS2, ICS3	DPC	FE
Define and prioritize patients’ medical problems and generate appropriate differential diagnoses	PC1, PC2, PC3, MK1	DPC, FR	FE
Develop rational, evidence-based management strategies	PC2, PC3, MK1, SPB2, SPB3, PROF3, PBL4	DPC, FR, MR, EBM	FE
PGY-1—Ability to make basic interpretation of chest and abdominal x-rays and electrocardiograms PGY-2/3—Develop and demonstrate proficiency in above	MK2	DPC, FR, MR DPC, FR, MR	FE, IE FE, IE
PGY-1—Ability to perform pelvic examination under supervision PGY-2/3—Ability to perform pelvic examination	PC4, MK2 PC4, MK2	DPC, ACS, AM DPC, ACS, AM	FE FE
Ability to recognize the physical findings of important medical illnesses	PC1, PC2, PC3	DPC, MR, MM	FE, MC, CEX
Willingness and ability to help patients engage in strategies of disease prevention	PC2, MK1, MK2, SBP3, PROF1, PROF3, ICS1	DPC	FE, SPE, MC

B. Medical knowledge
Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of medical patients in the outpatient setting	PC1, PC2, MK1	AM, DPC, PIP, JC, NC, MR	FE, IE, PIP
Access and critically evaluate current medical information and scientific evidence relevant to patient care in outpatient setting	SPB2, PBLI4	DPC, JC, NC, EBM, MR	FE, IE
PGY-1—Understand basic pathophysiology, clinical manifestations, diagnosis, and management of medical illnesses seen by a general internist in the ambulatory setting PGY-2/3—Develop and demonstrate in-depth knowledge of above	PC1, PC2,MK1 PC1, PC2, PC3, MK1	DPC, NC DPC, NC	FE, IE FE, IE
PGY-1—Recognize the indications for and basic interpretation of chest and abdominal x-rays, electrocardiograms, and pulmonary function tests PGY-2/3—Develop and demonstrate in-depth knowledge of above	PC1, MK2, SBP3 PC1, MK2, SBP3	DPC, MR, ACS DPC, ACS, MR	FE, IE FE, IE
PGY-1—Learn indications for and basic interpretation of standard laboratory tests, including blood counts, coagulation studies, blood chemistry tests, urinalysis, body fluid analyses, and microbiologic tests PGY-2/3—Develop and demonstrate in-depth knowledge of above	PC1, MK2, SBP3 PC1, MK2, SBP3	DPC, MR DPC, MR	FE, IE FE, IE
PGY-1—Familiarity with basic principles of disease prevention, including adult immunizations, cardiovascular risk assessment, prevention of cardiovascular disease, screening for cancer, prevention of osteoporosis, and cessation of tobacco PGY-2/3—Develop and demonstrate in-depth knowledge of above	PC2, MK1, MK2, SBP3, PROF3, ICS1 PC2, MK1, MK2, SBP3, ICS1	DPC, ACS, PIP, AM DPC, ACS, PIP	FE, PIP FE, PIP
Appreciation of the evolution of chronic conditions over time	PC1, PC2, PC3,	DPC, NC, AM, ACS	FE
PGY-1 —Basic familiarity with pathophysiology, clinical manifestations, and nonoperative management of common musculoskeletal conditions, including occupational and sports-related injuries PGY-2/3—Develop and demonstrate in-depth knowledge of above	PC1, PC2, PC3, MK1 PC1, PC2, PC3, MK1	DPC, ACS, CC, NC, AM DPC, ACS, NC, AM	FE, IE FE, IE
PGY-1—Basic familiarity with pathophysiology, clinical manifestations, and medical management of common gynecological conditions, including acute salpingitis, vaginitis, dysmenorrhea, irregular menses, and menopausal symptoms PGY-2/3-Develop and demonstrate in-depth knowledge of above	PC1, PC2, PC3, MK1 PC1, PC2, PC3, MK1	DPC, ACS, AM, NC DPC, ACS, AM, NC	FE, IE FE, IE
PGY-1 —Basic familiarity with pathophysiology, clinical manifestations, and medical management of common otolaryngological conditions, including acute and chronic sinusitis and allergic rhinitis PGY-2/3—Develop and demonstrate in-depth knowledge of above	PC1, PC2, PC3, MK1 PC1, PC2, PC3, MK1	DPC, ACS, NC, AM DPC, ACS,AM,	FE, IE FE, IE
PGY-1—Basic familiarity with pathophysiology, clinical manifestations, and management of common ophthalmologic conditions, including minor ocular injuries and conjunctivitis PGY-2/3—Develop and demonstrate in-depth knowledge of above	PC1, PC2, PC3, MK1 PC1, PC2, PC3, MK1	DPC, ACS, NC, AM DPC, ACS, NC, AM	FE, IE FE, IE
Familiarity with special features of diagnosis, interpretation of tests, and management of illnesses in a geriatric population	PC1, PC2, PC3, MK1, MK2, PROF3	DPC, SL, AM, NC	FE, IE

C. Interpersonal skills and communication
Communicate effectively with patients and families	PROF1, PROF3, ICS1	DPC	FE, SPE, PE
Communicate effectively with physician colleagues at all levels	PC5, SBP1, SBP4, PBLI3, ICS2	DPC, PC	FE, PR
Present information on patients concisely and clearly, both verbally and in writing	PROF1, PROF3, ICS1, ICS3	DPC, MR	FE, PR, NE, MRF, ABF

D. Professionalism
Interact professionally toward patients, families, colleagues, and all members of the healthcare team	SBP1, PBLI3, PROF1, ICS1, ICS2	DPC	FE, PR, NE, PE, SPE
Acceptance of professional responsibility as the primary care physician for patients under his/her care	PC3, PBLI1, PROF2, PROF4	DPC	FE
Appreciation of the social context of illness	PC2, MK1, PROF3, ICS1	DPC	FE, SPE
Understand ethical concepts of confidentiality, consent, autonomy, and justice in the outpatient setting	PROF1, PROF4	DPC, EC	FE, PE
Understand professionalism concepts of integrity, altruism, and conflict of interest in the outpatient setting	PROF1, PROF4	DPC, EC	FE

E. Practice-based learning and improvement
Identify and acknowledge gaps in personal knowledge and skills in the care of ambulatory patients	PC2, PC3, PBLI1, PBLI3	DPC, PIP	FE, PIP
Develop and implement strategies for filling gaps in knowledge and skills	SPB2, PBLI1, PBLI2, PBLI4	DPC	FE, IE, HEC
Commitment to professional scholarship, including systematic and critical perusal of relevant print and electronic literature, with emphasis on integration of basic science with clinical medicine, and evaluation of information in light of the principles of evidence-based medicine related to the outpatient world	PBLI2, PBLI4, PROF4	DPC, EBM, JC	FE, JCF, ABF

F. System-based practice
Understand and utilize the multidisciplinary resources necessary to care optimally for clinic patients	PC3, PC5, SBP1, SBP4	DPC	FE
Collaborate with other members of the healthcare team to assure comprehensive patient care	SBP1, SBP4, PBLI3, PROF1	DPC	FE
Use evidence-based, cost-conscious strategies in the care of outpatients	MK2, SBP3	DPC, SS	FE
Effective collaboration with other members of the healthcare team, including nurses, clinical pharmacists, occupational therapists, physical therapists, nutrition specialists, patient educators, speech pathologists, respiratory therapists, enterostomy nurses, social workers, and providers of home health services	SBP1, SBP4, PROF1	DPC	FE
Knowing when and how to request medical consultation and how to utilize the advice provided	PC5, SBP1, PROF1	DPC	FE
Consideration of the cost-effectiveness of outpatient diagnostic and treatment strategies	MK2, SBP3	DPC	FE
Knowing when to refer patients to specialists in orthopedics, gynecology, otolaryngology, and ophthalmology	PC5	DPC, ACS, AM	FE
Knowing when to consult or refer a patient to a medical subspecialist	PC5	DPC, ACS	FE
PGY-2/3—Willingness and ability to teach medical students and PGY-1 residents	PROF2, ICS2	DPC, RAE	FE, PR

1. Legend for milestones competencies (per ACGME reporting milestones): PC Patient care, MK Medical knowledge, SBP System-based practice learning, PBLI Practice-based learning improvement, PROF Professionalism, ICS Interpersonal and communication skills
2. Legend for learning activities: ABS Ambulatory block series, FR Work and teaching rounds, MM Morbidity and mortality, AM Ambulatory month, GR Grand rounds, MR Morning report, DPC Direct patient care, EBM EBM week, NC Noon conference, EC Ethics conference, JC Journal club, PIP Performance improvement project
3. Legend for evaluation methods for residents: AM Ambulatory month, PR Peer review, ABW Ambulatory block workshop feedback, SPE Standardized patient evaluation, FE Faculty evaluations, PE Patient evaluation, IE In-service exam, MCEX Mini-CEX, CCC Clinical Competency Committee semiannual review, PCRM Patient care resource manager evaluation, OSCE Objective structured clinical examinations, MRF Morning report feedback, NE Nursing evaluations, JCF Journal club feedback

Appendix 4: Checklist for Curriculum Implementation

• Identify resources

  • Personnel required: faculty, staff, others

  • Time: faculty, learners, support staff

  • Facilities: space, equipment, sites

  • Funding/costs: direct and indirect costs

• Obtain support

  • Internal: program director, department chair, learners, faculty

  • External: professional societies, if applicable (e.g., SGIM, AAIM)

• Develop administrative mechanisms to support the curriculum

  • Administrative structure of team

    • ◦ Necessary for delineating responsibilities and decision-making

  • Communication

    • ◦ Content to learners and faculty: includes goals and objectives, information about curriculum, facilities, scheduling, changes, evaluation results

    • ◦ Mechanisms: email, meetings, website, etc.

  • Operations

    • ◦ Preparation and distribution of schedules and curricular materials

    • ◦ Method of collecting, collating, and distributing evaluation data

    • ◦ Process for revisions

• Anticipate and address barriers

  • Financial

  • Competing demands

  • People: attitudes of learners and faculty, faculty without enough time, authority, etc.

• Introduce curriculum in stepwise fashion

  • Pilot project

  • Phase-in

  • Full implementation

Adapted from: Kern DE, et al.: Curriculum Development for Medical Education – A Six-Step Approach, 2nd edition. Baltimore: The Johns Hopkins Univ. Press. 2009

Appendix 5: Sample Mini-CEX for Gynecological Examination

Resident: ____________________________

Date: _______________________________

Supervisor: __________________________

Please rate the resident on the following criteria:

	Poor/not done	Minimal/adequate	Excellent
1. Proper patient positioning	1	2	3
2. Communication with patient during exam	1	2	3
3. Inspection of the external genitalia	1	2	3
4. Use of speculum (insertion and removal)	1	2	3
5. Inspection of vaginal walls and cervix	1	2	3
6. Obtained sample for Pap smear and/or wet mount/culture	1	2	3
7. Bimanual examination	1	2	3
8. Examination for inguinal adenopathy	1	2	3
9. Overall rating	1	2	3

Do you feel this resident is competent in performance of the pelvic exam? Yes No

Please provide any additional comments below:

Appendix 6: Sample 18-Month Curriculum for x + y Clinic Design, Repeated Twice over Residency

Block	Theme
1	Introduction to office-based practice I
2	Screening, prevention, population health
3	Pain management/musculoskeletal
4	Cardiology
5	Psychiatric disease
6	Pulmonary
7	Infectious disease/HIV
8	Endocrine
9	Gastroenterology
10	Renal
11	Geriatrics
12	Women’s health
13	Neurology/dermatology
14	ENT/ophthalmology/hematology
15	Palliative
16	High-value cost-conscious care
17	Urban curriculum
18	Career development and wellness

Sample 36-month curriculum for traditional, weekly half-day clinic design

Month	Topics
	Year 1	Year 2	Year 3
July	Billing and coding	Billing and coding	Billing and coding
August	Preventative services: vaccine/cancer screen	Preventative services: vaccine/cancer screen	Preventative services: vaccine/cancer screen
September	Type 2 diabetes mellitus	Preoperative evaluation	Sexually transmitted diseases
October	Hypertension	Coronary artery disease	Geriatric wellness
November	Hyperlipidemia	Obesity	Congestive heart failure
December	Panel management	Panel management	Panel management
January	Depression/anxiety	Hypogonadism and erectile dysfunction	Chronic pelvic pain and dysmenorrhea
February	Chronic pain syndrome	Gout vs. osteoarthritis	Women’s health
March	URI vs. sinusitis	Fibromyalgia	Hepatitis C
April	Asthma and COPD	CVA/TIA	Atrial fibrillation
May	Thyroid disease: hypo-/hyperthyroidism	GERD	Community-acquired pneumonia vs. influenza
June	Transitions of care	Migraines vs. tension headaches	Osteoporosis and vitamin D deficiency