Ambulatory Program - Internal Medicine Residency

Our residents receive extensive training in ambulatory medicine through their continuity medical clinics, subspecialty practices, acute walk-in clinics, and private practices. Through our noon core curriculum and ambulatory conferences, residents expand their primary care knowledge in both didactic lectures and small group discussions. The Associate Program Director for Ambulatory Education and the Primary Care Chief Resident are responsible for development and implementation of the ambulatory curriculum.

Continuity Medical Clinics

Residents immerse themselves in their a continuity medical clinic throughout their residency training at 1 of 4 sites:

• University Health Center (UHC)
• Primary Care Clinics at the VA
• Faculty Practice Office (FPO)
• Mercy Medical Center

Academic GIM 

Interns have a 2-week fall and spring Academic General Internal Medicine (GIM) block where they attend their continuity clinics in the afternoons and have a variety of learning sessions in the morning. During the fall Academic GIM block, interns attend primary care conferences, simulation and ultrasound sessions, literature in medicine, mentorship meetings, and wellness. 

	Mon	Tues	Wed	Thurs	Fri
Week 1 Mornings	Ultrasound Sim	Practice Based Learning	Lit in Medicine & Yale Curriculum	Wellness Check-In	Mentorship meeting
Week 1 Afternoons	Continuity Clinic	Continuity Clinic	Continuity Clinic	Continuity Clinic	Continuity Clinic
Week 2 Mornings	Opioid Use Disorder Didactics	ACLS Sim & Mock Codes	Journal Club	Ambulatory Hot Topics	Practice Based Learning
Week 2 Afternoons	Continuity Clinic	Continuity Clinic	Continuity Clinic	Continuity Clinic	Continuity Clinic

The spring Academic GIM block has a similar schedule with interns rotating in GIM and subspecialty outpatient practices that meet their learning needs and career goals. They also participate in leadership and teaching skills workshop to help prepare them for their PGY2 year. 

FleX+Y -  A novel X+Y system

Upper level residents attend continuity clinics in six 2-week blocks using a modified X+Y structure. The ambulatory Y blocks are strategically positioned to give residents flexibility for family and personal events, a well-deserved “rest” from inpatient rotation, or for interviewing for fellowships/jobs. We call our system -- FleX+Y. 

A typical 6 month schedule can have X+Y patterns of 6+2, 4+2 or 8+2, with

• X = inpatient rotations, electives, ER and vacation time
• Y = ambulatory time.

1A	1B	2A	2B	3A	3B	4A	4B	5A	5B	6A	6B
GIM Inpatient	GIM Inpatient	Elective	Y	ER	MICU	Y	MICU	Elective	GIM Inpatient	GIM Inpatient	Y
6 Weeks			2 Wks	4 Weeks		2 Wks	6 Weeks				2 Wks

                  

During their Y blocks, residents attend their continuity clinic in the afternoons and choose outpatient electives during the mornings. These electives include medical subspecialty practices, primary care for the underserved, community private practices, research, and quality improvement. Our Primary Care Chief Resident works with each resident to individualize their morning sessions to meet their career needs -- whether they are deciding among various subspecialties or primary care, to help solidify their commitment to a particular field.

Ambulatory Education

Consolidating continuity clinics into 2-week blocks allows residents to focus and build their ambulatory skills and patient panel, provide outpatient exposure to subspecialty care and allow for dedicated time for research and QI.

To augment their outpatient education, we have several didactic lectures, small group sessions, and interprofessional pathways our residents can participate in both during their Academic GIM and Ambulatory Y blocks:

• Primary care conferences.  Using the Yale Office-Based Curriculum as a guide, Senior residents lead small group sessions on various outpatient medicine topics with GIM faculty helping to facilitate discussions
• Opioid Use Disorder Education.  Interns receive early didactic lectures on opioid use disorder, buprenorphine waiver training, and harm reduction with special focus on the social determinants of health in this challenging patient population. Senior residents have the opportunity to rotate in buprenorphine clinics, methadone clinics, and syringe exchange programs. 
• Journal Club.  Senior Residents lead discussions on the most recent medical literature, with active participation by Medicine faculty to help integrate evidence-based medicine with real clinical scenarios. 
• Inter-professionalism Pathways. We currently have 3 inter-professionalism pathways in Endocrinology, Infectious Disease, and Hematology and Oncology – Providing those residents that are interested with the opportunity to gain more in-depth education and exposure and a potential to gain a Certificate of Excellence in these fields.
• Resuscitation simulation and Ultrasound Session. While not ambulatory-centric, these sessions allow residents to work with ED, Anesthesiology, and Critical Care faculty and fellows to build the skills and confidence in performing procedures and leading codes for when they return to their inpatient rotations.