Rotation: Internal Medicine Outpatient Clinic (Texas Tech Clinic)
Site:
- TTUHSC Outpatient Clinic 1400 Coulter Ave
Instructors:
- Drs. Cutts, Khandheria, Weis, Werner, Wilson and others.
Makeup of team(individual continuity clinic):
- Attending preceptor will directly supervise 1-4 residents per half day. PGY-I, PGY-II and PGY-III residents.
Days per week:
- 1/2 day per week
Usual time of attending rounds (meeting place):
- Clinic hours 1:00 pm to 5:00 pm. The attending will discuss each patient and will examine problem patients as well as all PGY-I patients during these residents' first 6 months.
Types of patients encountered:
The resident will care for post-pubertal male and female patients. The resident will obtain a familiarity with a wide variety of adult care including acute and chronic processes and preventative screenings such as:
- Health exam
- Perform a comprehensive history and physical.
- Complete age appropriate screening.
- Perform an athletic physical, as needed.
- Counseling
- Perform initial evaluation and counseling for alcohol, drug, and tobacco use/abuse, weight loss, safe sex, contraceptives, domestic violence.
- Preoperative evaluations
- Communicate with surgical and subspecialty consultants.
Educational goals/competencies:
Patient care:
The resident will maintain a continuity care practice addressing common ambulatory complaints such as fatigue cough, dyspnea, chest pain, palpitations, abdominal pain, nausea, weight loss, heartburn, urinary incontinence, hematuria, constipation, diarrhea, joint pain, joint swelling, memory loss, depression, insomnia, red eye, allergic disorders, upper respiratory infection, dizziness, anxiety, eating disorder, panic disorder, dysfunctional uterine bleeding, menopausal dysmennorhea, pelvic pain, and sexual dysfunction. The resident will also evaluate and manage multiple chronic medical conditions and provide preventative health maintenance.
Medical knowledge:
The resident will develop a method for evaluation and treatment disease processes in an outpatient care setting. The resident will obtain the knowledge and develop a process for formulating a differential diagnosis for acute complaints and managing multiple chronic medical issues, such as those listed in the Patient Care section.
The resident will be expected to perform additional reading from appropriate sources to supplement knowledge obtained by direct patient care.
In addition the resident will obtain competence in performing several outpatient procedures such as:
- Perform adequate Pap smear.
- Perform GC / Chlamydia cultures as indicated.
- Removal of benign skin lesions.
- Incision and drainage of skin abscesses.
- Joint injection for relief of symptomatic OA / inflammation (hip / knee).
- Joint aspiration for diagnostic purposes (knee, ankle, elbow)
- Cryotherapy application for skin lesions
Residents will become more comfortable and competent obtaining a medical history. Emphasis will be placed on completeness of history relating to previous evaluations, diagnoses, and social history. Especially in the outpatient continuity clinic, residents will have the opportunity to establish rapport with patients. This rapport will be essential in discussing such sensitive topics as end-of-life care, sexual dysfunction, and depression (to name a few).
Residents will be required to provide a complete written description of the patient's visit, including appropriate documentation to support level of care or billing. The resident will be expected to provide written communication in the form of letter to consulting or referring physicians when needed to supp0lement patient care.
Professionalism:
Residents will be expected to dress in business or business casual attire. Residents should not report for clinic wearing "scrubs" . Residents should communicate with patients in a respectful and direct manner. Residents should not alter level of professional communication due to ethnic or cultural differences. Residents should communicate with all patients with the same level of respect. Residents should not allow personal opinion to alter level of professionalism toward a patient.
Residents will interact with nursing and support staff in the clinic on a regular basis. Residents should not behave arrogantly toward these staff members. All members of the patient care team should be treated with respect. An appropriate level of communication should be used, taking into account that person's baseline knowledge of medical issues.
Residents will be expected to assist fellow residents with patient care when necessary (for instance, do not leave clinic at 3pm if a colleague has 5 patients left to see). A resident should offer assistance in these situations in order to develop the collegiality seen in the best internal medicine group practices.
Practice-based learning and improvement:
Residents will continue to learn by doing. Residents will have the learning process enhanced by direct feedback from the attending during patient evaluations Residents will also learn by observing the attending evaluation (history and physical examination) of some patients. Residents will be encouraged to ask questions to aid their treatment of patients in response to direct encounters with patients or interpretation of test/lab results. Further supplementation of knowledge will be obtained through texts and on-line resources listed below.
Systems-based practice:
One of the most difficult areas in outpatient medical care is learning the appropriate documentation level and billing level. Compliance officers will be immediately available for advice on billing/coding. Appropriate referral practices will be developed. Residents will be assisted in "appealing" a managed care refusal of care. Residents will become better informed about costs relating to operating a clinic (supplies, medications, gowns, etc.). Residents will become more adept at prescribing medications within outpatient medication formularies. Residents will become familiar with social services assistance for patients and how to optimize patient care for those with limited resources.
Text/references to be consulted:
Harrison's Principles of Medicine (14 th edition), on-line information Up-to-Date, MD Consult, Medline, MicroMedex. A small clinic library is maintained.
Methods of evaluation:
Each resident will have a mini-CEX performed per quarter. This is a directly observed patient evaluation. Quarterly formal evaluation forms are completed and discussed with the resident. A 360 degree evaluation process obtains input from office staff, nurses, patients and family members. This will be tabulated and presented for review to each resident.