Ambulatory Care Training

The Ambulatory Care Training section includes information on these important areas of interest:

Office Practices

Throughout three years of training, residents come to the office at least two or three half-days every week. There are up to six sessions a week on ambulatory blocks.

Residents work as members of a team to provide continuity of care to patients. Teams may include other residents, as well as fellows, faculty, and nurse practitioners/physician's assistants, nurses, medical assistants, and secretaries.

During patient care hours, there is always a preceptor available for consultation. On busy afternoons, as many as three preceptors are on duty. Preceptors are Family Medicine faculty, including an OB/GYN physician and a pediatrician, who are also available for informal consultation.

Each resident is occasionally scheduled for "teach-precepting" as well, when a faculty member spends half a day observing (and often videotaping) the resident's interactions with patients. The experience comes with verbal and written feedback and suggestions.

Patients from the practice admitted to the hospital are officially assigned to the Family Medicine faculty member on call (the "attending"). But as schedules allow, the patient's primary resident is expected to function as the attending, in consultation with the on-call faculty. This is useful experience in managing acute illnesses. It synthesizes inpatient and ambulatory training.

Another aspect of ambulatory training is telephone management. Second- and third-year residents on family medicine and elective rotations cover the calls for the practice when the office is closed. For backup, there is always a faculty member available for questions, and all emergency room calls go directly to the faculty on call. Residents learn important skills here: how to decide which patients can safely wait until the next office session, which can be treated empirically, and which need to be seen acutely. Monday morning conference is a report on interesting or problematic patients from the weekend on-call, with discussion and suggestions generated by the faculty and residents present.

PGY-3 Ambulatory Skills Block

The primary goal of this four-week block is to expand and refine the skills needed to see patients efficiently, confidently and competently. The emphasis is on developing an individualized outpatient practice style, with faculy supervision. The month includes continuity-patient care sessions, individualized skills sessions, team-centered care functions and a practice management project. Residents are encouraged to individualize their learning experience. Opportunities exist to pursue interests in family counseling, clinical protocol development, office procedures, gynecology, sports medicine, behavioral change techniques, and more.

Psychosocial Medicine Block

This aspect of our training makes us unique nationally. The psychosocial medicine program is designed for residents to develop personal and professional patient skills. Family physicians are more than a sum of subspecialties. We communicate with patients in a way that sets us apart, while still functioning as excellent clinicians. The broad scope of family medicine practice brings the physician in contact with patients in every part of the life cycle from birth to death. It covers health care from wellness to illness, over a spectrum of social classes, ethnicities and household configurations. Residents learn the patience, flexibility, and experience needed to work with such diversity.

The Family Medicine Residency Program, as a whole, promotes the skills and attitudes most helpful to future practice. Learning is enhanced by individual supervision, videotape review, and case consultation. Teaching psychosocial medicine is an integral part of the curriculum.

Mental health counseling services are provided at the Family Medicine Center. Residents refer patients for counseling, and consult and collaborate with mental health professionals.

A four-month Psychosocial Medicine Block rotation in the second year focuses on amulatory skills. It is spent at the Family Medicine Center, with some weekly sessions in Psychiatry at Strong Memorial Hospital. Residents spend 40% of their time in their outpatient practice, consolidating many of their outpatient skills. The rest of the time is divided among various outpatient-based primary care mental health experiences.

Residents participate in a Family Systems Medicine Practicum co-taught by a family physician and a family therapist. The practicum allows residents to expand their knowledge and skills in family systems, applying lessons directly to their own patients under close supervision. Included are short-term primary care counseling sessions, core seminars, and educational experiences in alcoholism and chemical dependency, parent counseling, eating disorders, psychopharmacology, and child psychiatry. Residents also have their own intensive small-group experience with an analytically oriented psychiatrist. This group provides an opportunity for self-reflection and education about the dynamics of small groups. In sum, the Psychosocial Medicine Block rotation is pivotal in the resident's development as a family physician.

Sample Three-Year Schedule—Blocks

Year	1st	2nd	3rd
1	Peds OPD	ED	Ger
2	Peds SCN	Peds	Med
3	OB	Peds OPD	Med
4	OB	Med	OB or SCN
5	Med	FM*/Elect	OB or Elect~
6	Ophth/ENT/URO*	PSM	Elect~
7	Derm	PSM*	Peds Ward
8	ED (Surg)	PSM	Elect**
9	Med	PSM	Elect~
10	Inpt	Med	Ortho
11	Surg	Amb Peds	Card/ICU
12	ICU	GYN/OB	FM Amb Skills
13	SCM	OB Or Elect	Elect~

*One week Night Float on Medicine
**Two weeks Night Float on Medicine
~Minimum 4 sessions/week in our continuity practice (unless on off-site elective)
SCM–Social and Community Medicine
PSM–Psychosocial Medicine

Community Medicine Block

In the final block of the PGY-1 year, residents participate in a month-long curriculum based in the Family Medicine Center and in the community. It explores social and economic determinants of health and medical care. It also sharpens skills for community-level interventions. The month includes seminar discussions and project development (group and individual). The seminars touch on community-oriented primary care, social epidemiology, culture and health, medical economics/politics, and occupational health. Field trips to local industrial sites provide firsthand experience in occupational health issues. This block provides an important look at larger systems, especially the social contexts of how medical care is delivered and how health or illness is determined.

The month also gives residents a chance to meet as a group after the demands of the first year, and to reaffirm their commitment to family medicine. The group-generated project involves a limited community intervention or data-gathering endeavor, to be finished within the month. This project could inspire a resident's research pursuit over the next two years. In PGY-2 and PGY-3, residents are required to participate in a supervised community project of their own choosing.

Procedural Medicine Block

Supervised workshops on many simple procedures are provided as part of the core teaching. These include skin surgery, casting and splinting, joint injection/aspiration, and gynecological procedures. Gynecological procedures done at the Highland Family Health Center include IUD insertion, endometrial biopsy, completions of miscarriages, colposcopy, and vaginal ultrasound.

A two-day workshop in colposcopy is held in conjunction with the OB/GYN department every year, and is specifically geared towards residents. A weekly colposcopy session is scheduled at the Highland Family Health Center, which is available to all residents. A bi-weekly dermatological session at the Highland Family Health Center site is designed for resident teaching. In addition, the Rochester medical community is rich in opportunities to obtain further procedural skills not available on site at the Highland Family Health Center.

Subspecialty Requirements

The American Board of Family Practice requires that residents take training in several specific fields in order to become board-eligible. These requirements include a minimum of 140 hours of orthopaedics, 60 hours of dermatology and structured experiences in ophthalmology, ENT, and urology. Three blocks are scheduled in the first year to meet these requirements. Additional time is available during the second or third year, and there's a dedicated block of musculoskeletal medicine in the third year. We enjoy a very collegial relationship with the University Sports Medicine clinic, and residents regularly rotate through that office.

Weekly Schedule at the Highland Family Health Center

Core curriculum takes place every Thursday afternoon, and is repeated two weeks in a row so that all residents may attend. Each resident (half of a pair) attends core curriculum every other week. Generally these afternoons are divided as described below. But the structure also provides the opportunity to present integrated material in longer sessions, afternoon skill workshops, or other new teaching approaches. In addition to core curriculum, several focused conferences take place weekly. For more, see the description that follows.

Teaching Afternoon Schedule (Thursdays)

1:00 - 1:55 OB Core
1:55 - 2:45 Procedures Core/Alternate Core/Faculty Resident Interface Committee (FRIC)
2:50 - 3:45 Biomedical Core
3:55 - 4:50 Psychosocial Core
4:50 - 5:30 Balint

Weekly Schedule

Time	Monday	Tuesday	Wednesday	Thursday	Friday
8:00 – 8:30 a.m.	Morning Report	Grand Rounds	Difficult Case Conference		Journal Club 1st & 3rd
8:45 a.m. – 12:15 p.m.	OFFICE HOURS				PGY-3 Practice Management 1st & 3rd
1:15 – 1:45 p.m.	Office Hours 1:15 – 5:00 p.m.	Outpatient Report or Team Meeting	Outpatient Report or Team Meeting	Teaching and Balint 1:00 – 5:30 p.m.	Office Hours 1:15 – 5:00 p.m.
1:45 – 5:00 p.m.	Office Hours 1:15 – 5:00 p.m.	Office Hours 1:45 – 5:00 p.m.	Office Hours 1:45 – 5:00 p.m.	Teaching and Balint 1:00 – 5:30 p.m.	Office Hours 1:15 – 5:00 p.m.

Explanations of Scheduling

On most patient services, partners alternate afternoon office hours. One resident goes to the office Mondays, Wednesdays, and on alternate Thursdays. The other resident goes to the office Tuesdays, Fridays, and on alternate Thursdays.

The teaching sessions (from 1:15 p.m. to 1:45 p.m. on Tuesdays and Wednesdays) focus on common problems within ambulatory care.

Team meetings are from 1:15 p.m. to 1:45 p.m. Tuesdays or Wednesdays, during the first and fourth week of each block.

Monday and Thursday evenings and Saturday morning office hours are staffed by residents on elective and other ambulatory blocks.

An abbreviated patient care session on Thursday afternoons is staffed by nurse practitioners and faculty.

Conferences

Core Curriculum. A series of topics in the Biomedical and Psychosocial spheres of family practice. These teaching conferences are held Thursday afternoons at the Highland Family Health Center. Because of resident pairing, each session is presented twice, two Thursdays in a row, so each resident has an opportunity to attend on alternate weeks (see Weekly Schedule above). These sessions are led by faculty, visiting speakers, and third-year residents. Formats range from the straight didactic, to case-oriented presentations, to open discussion, to hands-on skill workshops. There is a separate psychosocial medicine curriculum for PGY-1s; PGY-2s and PGY-3s meet together.

The Biomedical Core Curriculum is presented to all residents on a three-year cycle. The topics focus on aspects of care specific to ambulatory practice. Presentations are by the Family Medicine faculty. Topics vary, from adolescent health care and joint injections, to breast disease and refugee health assessment.

The Psychosocial Medicine Core Curriculum is a three-year program of seminars held every other week. The focus is on the basics of interviewing, the family in family medicine, the biopsychosocial/systems approach to patient care, and topics important in primary care. Faculty includes family physicians and family therapists/mental health providers.

OB Core. Presented weekly by the obstetrician on faculty with the assistance of the OB fellows. This portion of the teaching afternoon addresses OB and GYN topics and related needs of inpatient and ambulatory care.
Procedures Core. To meet the growing interest in outpatient procedures, this period is dedicated to "hands on" experience. Among the topics: suturing, endometrial biopsies, skin and nail procedures, ultrasounds, and casting.
FRIC (Faculty Resident Interface Committee). On alternating weeks, residents, faculty, and chiefs meet to discuss residency issues.
Balint Group. A personal awareness group facilitated by a Family Medicine faculty and a family therapist to explore doctor/patient relationships. It helps develop the resident's identity as a family physician.
Conference. A faculty-led conference held two or three mornings a week, before office hours. The format varies from a review of patients evaluated while on-call to videotape reviews to journal club.
Outpatient Report. An initiative of chief residents, this twice-weekly report involves presentation of case-based topics, just before afternoon patient care sessions begin.
Pediatric Topics. In response to residents' initiative, this series complements regularly scheduled pediatric topics in the outpatient report. Topics are seasonally relevant and focus on outpatient assessment of pediatric problems.
PGY3 Teaching Mornings. On alternate Friday mornings, PGY-3s participate in focused, interactive conferences. The curriculum includes practice management, quality assurance, and critical appraisal. It is also an opportunity for senior residents to work on joint projects.
Special Conferences. Residents may use their CME stipend, and up to one week per year, for conferences.
Spring Retreat. This is an annual, full-day retreat. Faculty and residents come together to take a constructive look at the residency. Areas that may need "renovation" are discussed and work plans are developed.
Fall Retreat. This half-day retreat allows residents to make suggestions to chief residents on either specific rotations or the program in general.

Research

Support for research is readily available. Many faculty members are actively involved in ongoing studies. Areas of research interest include healthcare disparities; physician/patient communication regarding HIV and risk behavior; smoking and maternal health; adolescent health; fibroma treatments; reproductive health; mammography education; and health care needs of the hearing impaired.

Electives

Open time for residents to pursue individual areas of interest or perceived areas of weakness. The most common elective involves work with a preceptor in a given field. Other formats (independent study or a research project) require prior approval from the residency director and chief resident. During these blocks, residents spend about 20 hours a week fulfilling board requirements or elective training; they spend four half-days a week at the resident's family medicine office. During PGY-2 and PGY-3 year ambulatory blocks, call is limited to telephone call for the practice, and average slightly more than once a week.

Two blocks of "off-site electives," with pay, are an option during PGY-2 and PGY-3 years. Residents often choose to work in a medically underserved environment during this time, in either a rural or urban setting. Many residents also choose to work in developing countries.