Ambulatory Block

Schedule and Orientation

 
February 3rd, 2012 Block 8
PGY II and III Residents

 

 

 

 

1.      Goals and Objectives

The main goal of the program is to teach residents the comprehensive and continuous care of a panel of patients in the ambulatory setting, focusing on the management of acute and chronic illnesses in a diverse patient population. Residents will learn to deliver high quality, updated, evidence-based medicine. Residents will learn to make rational, cost-effective, and patient centered clinical decisions for their patients. The care of the “whole patient” is emphasized, paying special attention to helping residents develop strong patient advocacy attitude and skills, and cultural awareness.  Principles of health promotion and disease prevention and screening are also major components of the curriculum.

 

Rotation specific objectives:

·         Residents will be able to demonstrate the ability to provide compassionate, efficacious, and efficient, patient care to patients in the ambulatory setting

·         Residents will demonstrate the ability to care for ambulatory patients with a broad range of acute and chronic medical conditions, and learn to become their patients care coordinator and advocate.

·         Residents will demonstrate willingness to continuously improve and self assess their ambulatory knowledge base and clinical practice process.

·         Residents will review the principles of epidemiology, pathophysiology, therapeutics, and prevention in the management a diverse set of illnesses. Residents will demonstrate the ability to retrieve and critically review and apply relevant medical literature to the care of their patients.

·         Residents will demonstrate an understanding of individual and group quality improvement initiatives.

·         Residents will be able to appropriately access the services of the multi-disciplinary team members for the care of their patients (including social workers, nurses, medical assistants, patient representatives, home visit nurses, physical therapist, nutritionist, interpreters, and others…). Residents will participate in home visits and clinic disease management committees.

·         Residents 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 understand the approach to, and care of the “whole patient”.  Residents will demonstrate at all times, ethical, humanistic, respectful, empathetic, culturally competent, and professional demeanors in all their interactions with patients, staff, and peers.

·         Residents will learn indication/contraindication and techniques of office based procedures.

·         Residents will be able to communicate effectively and efficiently on written medical records

·         Residents will be familiar with the workings of an office practice, including important practice concepts of scheduling/billing/compliance/telephone medical triage.

This syllabus is also available on the medicineclinic.org website.  Look in Orientation, under Ambulatory Block.

 

 

In order to standardize the residents’ exposure to the essential aspects of ambulatory medicine, each OPD blocks have been assigned specific subspecialty clinics and didactic conferences. 

OPD Block

Didactics

Sub/Specialty Experience

Jr. OPD 1* Residents

Clinical Epidemiology II, OPD Wed MR, Friday Division of GM Conference, Hazelden Training (not every block), Panel Review, Writing Notes Conf.

(Endocrine Block)- Naomi Berrie Diabetes, Inpt Diabetes, endocrinology, AIM DM cln, Derm, home visits with Dr. Jones

Jr. OPD 2 *

Residents

Blume Rounds¥,  Friday Division of GM Conference , Monday 8AM Psych Teaching Rounds, Panel Rev.

Sleep Clinic and Lab, Thyroid Clinic, Oncology, ENT Office with Dr. Storper

Sr. OPD 1*

OPD Wed AM MR, Division of GM Conference, AIM QI team activity, Chart review, Monday Psych teaching rounds

Derm Rounds, Chest,  ENT, GI, Endoscopy Suite, Preop, AIM DM management, Liver clinic

Sr. OPD 2* #

Teaching Sr.

Clinical Epi III, Blume Rounds¥, Division of GM Conference, Sr PIC (PIC),  TS Didactics, Monday Psych rounds, DM Rounds

(Rheum and Teaching Senior Block)-Lupus, Arthritis, Rheum   AIM DM management clinic, Tres

*Residents should attend Milstein MR on days not expected at 8am OPD conferences.

¥A schedule for resident presentation at Harkness is generated by the chiefs’ is posted in VC 2 conf and on the website

 

Evening clinics Evening clinics are scheduled for Junior OPD 1 residents, it starts at 5pm and end by 7pm.  Residents scheduled to work on walkin (W*) Thursday afternoons will not have even. clinic.

 

Subspecialty and Specialty Experiences (see schedule legend explanations, next page)

Residents will be scheduled to attend 2-4 subspecialty clinics per week.  It is a precious opportunity to broaden your ambulatory knowledge outside of primary care. Over the course of 3 yrs, we will provide a standardize exposure for all residents to over 20 specialty and subspecialty experience on and off campus. To enhance your own learning, please review the specialty specific FCIM curricular guide (on clinic website, look under orientation, ambulatory block, and “Specialty and Sub-specialty experience”) to help you develop some concrete learning goals during the sessions.

 

Walk In Clinic (Walk-in)–Room 214 Please be in clinic promptly at 9am or 1pm

This clinic accommodates regularly followed AIM pts who are acutely ill.  Residents will learn to provide thoughtful focused and efficient evaluations of urgent ambulatory complaints.  Given the busier pace here, residents need to focus on triage and focused management. The goal is not to provide a comprehensive or protracted primary care visit here.   This clinic’s volume is variable. We ask that you arrive on time, and although the 2 AM walk-in residents do not need to “clear out” the intake box before noon conference, both should work quickly enough to not overload the afternoon team. Do not “cherry pick” cases, take the 1st chart on top no matter what the complaint is. The triage RN will prioritize pts with more urgent complaints.

Walk-in Docs should also be on the look out for irregularly followed pts who are using walk-in excessively.  Read the PCP’s note, see how many appts are missed, and help plug these pts back into regular PCP care.  If there is no quick f/u appt for a pt who need a more comprehensive f/u appt, please book the pt with  any available AIM MD/NP for an interim follow up visit to advance care. Please SHM your walkin clinic note to the PCPs after visit so they are aware of your visit with his/her pt. (R click on your note).  

 

Pre-Op Clinic (Preop) Room AIM 240, Monday and Friday AM

Review your pre-procedure evaluation knowledge by reading the guidelines listed under Calculators section in  www.medicineclinic.org. Again the style of practice in this clinic is usually quite focused and concise, and often for the majority of patients who are either well, or referred for very low risk procedures (like cataracts), the approach is quite straight forward and the H&P itself is the main elements of the evals.   

 

AIM Diabetes Management Clinic –Evelyn Thompson RN VC 2-221 (small conf. room)

Residents assigned to this clinic will work alongside Ms. Evelyn Thompson, our DM RN to advance care of uncontrolled DM pts followed in our clinic.  Cases will be presented to the PIC at the end of the session. Please take a proactive role in learning how to use diabetic equipments (glucometers, needles) and engaging in pt counseling.

 

 

 

The Didactics- All conference located in VC 205 unless otherwise stated.

·         Clinical Epidemiology II and III lecture series with Dr. Palmas will meet in VC 205. It starts at 2pm on Friday.

·         Blume Rounds   1pm M-Fri Senior and Junior OPD 2 residents are scheduled to attend. Clinic for OPD 2 residents start after at 2pm.  Residents scheduled for onc, neuron, Hazelden are excused from Blume rounds.  A schedule for resident presentation at rounds is generated by the chiefs’ office and posted monthly in the VC 205 conf. room and online. On Fridays attend the Rheumatology Division Conference in Black Building Rm 1041 at 1pm, consult rheum cases will be discussed by the faculty.  Dr. Blume will monitor attendance here also.

·         Junior and Senior OPD1 residents  are expected at the Wednesday AM Outpatient Morning Report in room VC-205 at 8AM.  Conference topics will be emailed to you.  On the weekdays when you are not scheduled for OPD MR, all residents should attend Milstein MR.

·         Division of General Medicine Conference 8:00am Friday mornings in the Atchley-Loeb conference room on PH 8East

·         Naomi Berrie Diabetes Center NBDC consists of both didactic and clinical teaching and is coordinated by Dr. Robin Goland at the NBD Center, at the Russ Berrie Building- at 1150 St. Nicholas Avenue, 2nd Floor 2nd Fl Classroom (Tuck Library) at 10AM Tuesday (the 1st day)  

·         Hazelden Physician Addiction Medicine Training Center (Junior residents) At this downtown c.enter, residents will hear lectures, interact with patients, and attend AA meetings.  We will email you with registration packet 3 weeks before attending.  Hazelden is NOT offered this block.

·         Monday AM Psychiatry Intake rounds 8am VC2 –case base learning with Dr. Mark Petrini, intake style based on your questions/cases. (all OPD residents, except Jr OPD1 nite residents are expected to attend)

 

Other OPD Activities

The Observed History and Physical (PGY I residents)

In the first 2 years of training, all residents will perform one complete history and physical exam on a new patient in the presence of an attending physician. 

 

Senior Teaching Senior- PIC, Physical Diagnosis, Teaching Senior Rounds (OPD 2 PGY III):

In the teaching senior curriculum on OPD 2, residents will be given time to prepare and teaching afternoon Chief Conferences for the inpatient night residents. Residents will also co-precept interns with clinic attendings. In addition this month, residents will have the opportunity to participate in 2nd year med student teaching in the Physical Diagnosis with Dr. Gowda. For precepting, please read the “Shaping the Teaching Conversation” article on the Teaching Senior webpage on the medicineclinic.org website.

 

·   Physician Note Writing Cnference-   OPD 1 Jr residents will attend a conf with Dr. Chang reviewing the basics of physician note writing.  This session will occur on one Friday afternoon at 1pm (before Epi).

 

·   “Chart Rev”iew/Biannual Patient Panel Management Review- Using chart review worksheets, residents will use this opportunity to examine their own population (panel) management in certain chronic diseases,  as it relates to quality of care and communication of care in their panel of pts. It is also an opportunity to take a more systematic look at some processes and outcome measures in the care of your own patients with chronic illnesses. This is an exercise you will perform twice a year on OPD rotations. We will email copies of your assigned exercises (HTN/CHF, DM, Asthma, Readmission, Geriatric). Please be sure to complete and place in my mailbox (or by email) by the end of the rotation.    

 

·   Team QI- an independent team activity for the OPD 1 seniors. Residents will work with Dr. Chang at the beginning of the block to identify a system based problem in clinic. Using the 4 weeks of the block, residents will work as a team to collect information on the composition of the problem, and proposed (and possibly even test) new solutions to the problem.  For example, residents this past year have worked on projects of outpatient critical lab alerts, improving discharge process, medication reconciliation, telephone messaging, translator triaging, etc….   We will meet in my office at 1pm for the first session.

 

 

Clinic Evaluation

Rotation and Attending Evals- You will be asked to evaluate your outpt experience at the end of each OPD block. You will also be asked to evaluate all the clinic preceptors annually in May-June.

Trainee Evaluations- You will receive twice a year composite group evaluation from the clinic preceptors (this evaluation will be entered by our administrative staff –Luis Ducasse). These evaluation are based on your 6 month performance in continuity clinic as well as in your OPD block. We will also provide you a yearly clinic visit # report as a measure of your clinical exposure. Occasionally we do receive very specific comments about individual doctors from our patient visit surveys (Press Ganey Survey- post visit survey), that will also be provided to you when available.

 

The Sub-Specialty and Specialty Experiences

Residents are assigned to a variety of subspecialty sites to broaden their learning experience.  At many, special arrangements have been made to provide this invaluable learning experience for you.  You are expected to attend all of these assigned sessions.  Each clinic or private office is informed by writing each month of your expected presence.  We will do our best to notify you if a subspecialty clinic has been cancelled, however, given the sheer number of clinics involved, we ask that the residents call some irregularly scheduled clinics to ascertain the occurrence of the session prior to going there.  These clinics include lipids, osteoporosis, and orthopedic private office sessions.  Read below to check the location and timing of the clinic before attending.Please review the FCME defined specialty competencies before attending the clinics.  See explanation in curricular guide and medicineclinic.org website.   

 

Arthritis clinic (See rheum)

 

Cardiology (Cards) Clinic: AIM East, Dr. Elsa Giardina - Monday and Friday PM, Tuesday AM

 

(Chest): VC 10th Fl, Monday PM, report to clinic attending. Dr. Burkhart is the Medical Director.

 

Dermatology (Derm): Clinic-Atchley 12th Fl., Dr. Engler 50705

 

Derm Rounds (Derm Rds) - Monday 8 AM, page 1799 in advance to check location for meeting with Dr. Grossman and team. Dr. Grossman welcomes medical residents to participate in discussions on rounds.

(Endo)crine: Tuesday PM AIM East, Dr. Wardlaw, please report to attending of the day

Endoscopy Suite (see GI)

 

(ENT): Dr. Ian Storper, in his private practice in the Atchley Pavilion 7th floor Room 714 Thu AM 9 AM to 12pm. X 5-1906

 

Gastroenterology clinic (GI): AIM East, Thursday afternoon, Dr. Garcia-Carasquillo

GI Endoscopy Suite-Dr. Garcia and Dr. Rosenberg Herbert Irving Pavilion 13th Floor

 

(Home Visits) with the Home Bound Elderly Program: Tue afternoon 1pm when scheduled, please page or email Dr. Margrit Wiesendanger before the session to confirm meeting place. (this program is on hiatus)

 

Inpatient Diabetes (Inpt DM):   with Dr. Susana Ebner 5-4633, meet team at 9am at 6GS Room 306. Spend the morning with diabetologist and diabetes educators, you may be asked to see one pt and spend the rest of time rounding. (a 2 week-1month elective is also available for interested residents)  

 

 

(Liver): AIM East, Wed AM Dr. Garcia/Dove  

 

Lupus Clinic see Rheum: Monday AM AIM East

 

Naomi Berrie Diabetes Center (NBDC): Director Dr. Goland and Golden (contact Ms. Jenn Preval 851- 5494). The 1st day of training is focused on didactics, meet 10am Tue in the Tuck Library, 2nd Fl NBDM bldg (elevator in the back).  This day is then followed by 2 separate activities spread over the rest of the OPD block. The first is an individualized session, occurring each Wed afternoon where one resident is rotated to spend time in the Berrie Center clinical unit, shadowing patient care with either Dr. Caspar the Diabetic Ophthalmologist, or with one of the Diabetes specialist.  The second activity occurs as a group session on the Friday at 1pm, where the group will observe an insulin pump teaching class.  I will forward the monthly Berrie Schedule once finalized each month.

 

Breast Oncology (Onc):   Wed 1 PM Breast clinic Atchley 10th fl (Dr. Hershman)

 

Ophthalmology (Ophtho): Flanzer Eye Center 635 W. 165th St., Please be in clinic on-time at 1pm.  Report to the ophtho chief resident.  (DO NOT attend Harkness Report the day of clinic)

 

(Pain) Management Clinic: Coordinate Ms. Brant Dr. Weinberger 9am and 1pm x5-7114, call in advance to confirm clinic location of the day, the clinic sees patients both in Herbert Irving Pavilion-Garden, and PH Room 5th floor Room 500.  

 

(Rehab) Clinic:  Dr Chris Visco Rehab Medicine Harkness Pavilion 1st Floor Suite 199 Thu AM

 

(Rheum)atology/Arthritis/Lupus: This yr we are combining all the rheumatology rotations into one week for each senior. Your attendance will be tracked. AIM East, Monday AM, Tue AM Wednesday PM, Report to attending of the day. please read   “must read” rheum articles from “ambulatory reading list” on website.

 

Sleep Disorder (slp lab/cln): Dr. R Basner 304-7166 PH8 Room 859. The phone #s are 212-304-7166 and 212-305-7591 for the lab itself. Dr. Basner said to be there from 7:30 to 9:00, which is  when he reads the studies.  There is clinic after readings are done.

 

(Thyroid): Friday 1PM, Atchley Basement “Garden” level x 50983, Dr. McConnell combined surgery/endocrine clinic in Atchley Pavilion. Dr. McConnel welcomes you to come feel some thyroid nodules.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AIM Housestaff Practice On-Call Schedule                 

The objectives of telephone coverage are to provide after-hours phone consultation to our patients (preventing unnecessary and expediting necessary ER visits), and to provide hands-on experience for residents in “telephone medicine”.  When a pt indicates that they have an emergent call, the service will first page the first on-call resident to the HCI’s Physician Access Line 212- 517- 1114. The AIM Res acct # is 391 (you will be prompted to provide this acct # to the operator).   The second-call resident will only be paged if the first call resident fails to answer his/her beeper after 30 minutes. On-call residents do not cover phone calls for AIM attendings, NPs, these calls are taken by the attending on call (390).

 

A Webcis or Eclipsys Telephone Note should be completed for all important calls.  You should use SHM to FORWARD any non-urgent mssg handled to PMD. If you have any questions regarding how to respond to a particular pt call, page the AIM Attending-on-call (listing acct 390)  or myself to obtain more guidance.  If needed for urgent decision making, you can page your colleagues to see if they are available to call back and provide important info.*

 

On your assigned date, please make sure your beeper is kept with you, and NOT signed out for the night.  If preferred, you can notify the answering service to call you on your cell or home phone instead.  Please also inform the answering service supervisors, in advance of any switches. Swaps of phone call coverage must be communicated to the Answering Services. ("Attn HCI Supervisor"- email coverage@hlink.com or call 517-1114  re: acct 391)

·    week day phone coverage start at 5pm and ends 9am the  next day; Saturday/Sunday/Holiday shift start at 8am, and ends 8am the next day.

·    Please do not give the HCI physician access number out to patients, this is a MD only line.

 

 

1st call

2nd call

 

 

1st call

2nd call

3-Feb

Fri

Lin

Narula

19-Feb

Sun

Ng

Lin

4-Feb

Sat

Benvenuto

Lin

20-Feb

Mon

Turner-Lloveras

Ng

5-Feb

Sun

Doshi

Benvenuto

21-Feb

Tue

Funt

Turner-Lloveras

6-Feb

Mon

Waase

Doshi

22-Feb

Wed

Chudasama

Funt

7-Feb

Tue

 Chow

Waase

23-Feb

Thu

Benvenuto

Chudasama

8-Feb

Wed

Turner-Lloveras

 Chow

24-Feb

Fri

Camacho

Benvenuto

9-Feb

Thu

Poon

Turner-Lloveras

25-Feb

Sat

Poon

Camacho

10-Feb

Fri

Ng

Poon

26-Feb

Sun

Narula

Poon

11-Feb

Sat

Hassid

Ng

27-Feb

Mon

Funt

Narula

12-Feb

Sun

Chudasama

Hassid

28-Feb

Tue

Doshi

Funt

13-Feb

Mon

Waase

Chudasama

29-Feb

Wed

Hassid

Doshi

14-Feb

Tue

 Chow

Waase

1-Mar

Thu

Turner-Lloveras

Hassid

15-Feb

Wed

Narula

 Chow

2-Mar

Fri

Chudasama

Turner-Lloveras

16-Feb

Thu

Smilowitz

Narula

3-Mar

Sat

Smilowitz

Chudasama

17-Feb

Fri

Doshi

Smilowitz

4-Mar

Sun

Camacho

Smilowitz

18-Feb

Sat

Lin

Doshi

5-Mar

Mon

Lin

Camacho

 

 

 

 

6-Mar

Tue

Narula

Lin

 

*Very rarely on call residents have been asked by the NYPD or ME to agree to sign death certificates for pts who passed away at home. The ME will page you to review the pmhx and establish a hx of chronic or declining health so they can avoid an unnecessary autopsy and allow family to begin the burial process.  Use Webcis/Eclipsys to verify the pt’s hx/death as an “expected” event, if so, tell the ME that the PCP will be willing to sign. (Call attending on call if you are not sure). In the morning also contact the PCP -if not available- a PIC- to arrange for on-site death certificate signature completion (funeral home will send staff).  Only unexpected deaths should go to the City ME for formal investigation.