VA Subspecialty Ambulatory

Educational Purpose:

This rotation is intended to give upper level medical residents the experience of working with various sub specialty internal medicine patients in an ambulatory care setting. It is designed to develop the clinical skills required by a general internist when evaluating and managing sub specialty problems in the office setting. The rotation provides the residents with expert mentorship, direct supervision, and the resources to enrich the direct clinical experiences.

Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Residents are expected to:

PGY 1

PGY 2 and 3

1. To enhance the residents’ history taking and physical diagnosis skills.
2. To develop differential diagnoses and formulate a treatment plan in an outpatient subspecialty setting.
3. To manage the outpatient illnesses which are commonly cared for by the general internist.
4. To develop expertise in caring for outpatients with endocrine, cardiac, infectious disease, hematology, oncology, GI, nephrology, and pulmonary diagnoses.

Medical Knowledge Goals and Objectives:

Goal: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.

Residents are expected to:

PGY 1

PGY 2 and 3

1. To enhance the residents’ history taking and physical diagnosis skills.
2. To develop differential diagnoses and formulate a treatment plan in an outpatient subspecialty setting.
3. To understand the indications/need for appropriate outpatient subspecialty consultation.

Practice-Based Learning and Improvement Goals and Objectives:

Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning.

Residents are expected to develop skills and habits to be able to:

PGY 1

PGY 2 and 3

Systems Based Practice Goals and Objectives:

Goal: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Residents are expected to:

PGY 1

PGY 2 and 3

1. To develop expertise in caring for outpatients with endocrine, cardiac, infectious disease, hematology, oncology, GI, nephrology, and pulmonary diagnoses.
2. To understand the indications/need for appropriate outpatient subspecialty consultation.
3. To effectively work with an interdisciplinary team in the outpatient setting.

Professionalism Goals and Objectives:

Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Residents are expected to demonstrate:

PGY 1

PGY 2 and 3

Interpersonal and Communication Skills Goals and Objectives:

Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.

Residents are expected to:

PGY 1

PGY 2 and 3

1. To enhance the residents’ history taking and physical diagnosis skills.
2. To demonstrate interpersonal skills and to communicate effectively with patients and families.

Teaching Methods:

The majority of teaching on the VA subspecialty rotation is case-based, one-on-one teaching at the time of presentation to the clinic. This teaching can include demonstration of history taking or examination skills, modeling communication or Socratic exploration of medical knowledge. Residents present patients for in-depth discussion of differential diagnosis and therapy. Residents are expected to attend Noon Conferences during this rotation.

Mix of Diseases and Pathological Material:

Residents will see veterans with a wide variety of pathology from each of the internal medicine subspecialties.

Patient Characteristics:

Residents care for a diverse patient population with respect to age and ethnicity, though the population is predominantly male. 

Types of Clinical Encounters:

Cases will include consultations from primary care clinics and hospital discharges along with ongoing patients assigned to each subspecialty area. Residents have first contact with all patients.

Procedures and Services:

Residents have the opportunity to perform any ambulatory procedures in the various subspecialty clinics. All procedures are appropriately supervised by the attending physician. 

Supervision:

One or two upper level residents are assigned to this experience monthly. These residents independently evaluate patients as noted above. All patients are then presented to the attending physician. The attending physician directly supervises patient care and all procedures. Fourth year medical students are frequently assigned to the VA outpatient clinics each month and the resident actively participates in educating and supervising the student. The resident interacts with the entire interdisciplinary team including the social workers, nurse case managers, and clinical pharmacists.

Educational Resources to be Used and Reading Lists:

Each subspecialty clinic has texts available in the clinics. Further, the VA has numerous online resources including Up-To-Date.

Method of Evaluation of Resident Competence:

Residents are evaluated using the global evaluation form. Patient Care is assessed based on direct observation and complete review of all records. Medical Knowledge is assessed through direct questioning and observation. Interpersonal Skill and Communication is assessed by observation of interactions with patients and staff. The attending physician evaluates Professionalism through direct interaction and observation of the resident. Practice Based Learning is evaluated based on the ability to consult the literature and to improve their performance throughout the rotation. Systems Based Practice is assessed based on the interaction in the team care setting. Residents receive formative evaluation throughout the month.

The residents evaluate the rotation and the attending physicians through the E*Value system.