Ambulatory Education

IM - Ambulatory Team

Overview

Goal of OHSU's Ambulatory IM Residency Education

The goal of our ambulatory internal medicine program is to graduate residents who are knowledgeable, efficient, evidence-based, empathic, collaborative, patient-centered physician leaders, advocates, and expert communicators who are ready to practice primary care general internal medicine in any setting or pursue alternate career paths.

Objectives

  • Teach residents medical knowledge, skills and attitudes through direct patient care in varied settings, small group work, ambulatory reports, practice-based learning sessions, evidence-based medicine seminars, advocacy training, wellness and quality improvement sessions, and patient-safety projects to foster well-rounded graduates
  • Provide broad exposure to outpatient internal medicine ambulatory practices including primary care continuity clinics, as well as subspecialty internal medicine clinics and relevant non-internal medicine experiences through rotations at OHSU, VA, Old Town Clinic as well as Kaiser and select additional second clinic options
  • Explore communities and practices off the Hill (outside of OHSU and the VA hospital) and reflect on social structures that create wealth and poverty as well as promote health or invite disease through the social medicine block (three weeks during your intern year), local global health rotation (an elective if you choose to participate on the global health track), and program-wide advocacy training
  • Tailor your outpatient training by selecting a "Second Continuity Clinic" in your R2 and R3 years to gain mentorship and experience in a field you might pursue or area you want to explore

Clinic Week Components

Each year of residency consists of thirteen +1 clinic weeks, with three weeks of largely inpatient rotations between clinic weeks. Each clinic week consists of ten half days. This includes two half-day educational seminars, four primary care clinics and your continuity clinic site, and three specialty clinics assigned to you in three to six month rotations to support your development in becoming a well-rounded general internist. 

  • Interns have a third half-day educational seminar of Advocacy Training as well as the Teaching Improvement Science (TIS) Curriculum.
  • R2s and R3s have an administrative half-day for panel management and to schedule research and mentorship meetings or arrange for additional clinical experiences of their choosing. Additionally, R2s and R3s select a "2nd Continuity Clinic" site that they will attend for an entire year to gain mentorship and clinical experience in a field of their choosing.
    • 2nd Continuity Clinic Examples:
      • Hepatology clinic for those interested in GI fellowship
      • Electrophysiology clinic for those pursuing Cardiology
      • Benign Hematology for those pursuing hem-onc
      • OHSU HIV clinic for residents interested in HIV-Primary Care
      • Additional primary care clinics such as, Virginia Garcia Community Health Center and Multnomah County Health Clinic
      • Private physician-owned clinics in Portland, that serve specific and different populations that one's continuity clinic
      • Clinics in a more niche area in which a resident would like to hypertrophy their skills (Sports Medicine, Pre-op Medicine, Dermatology, Center for Integrative Pain Medicine, etc.).

Sample Schedules

All interns and residents attend half-day educational seminars on Tuesday mornings and Friday afternoons.  These seminars are composted of Primary Care Ambulatory Topics (PCAT, your outpatient general internal medicine curriculum), Ambulatory Report, Evidence-Based Medicine Sessions, and the Department of Medicine Grand Rounds.  The Intern-only education seminar on Wednesday mornings includes the Advocacy Curriculum and the Wellness and Improvement Science Curriculum.  

Primary Care Ambulatory Topics (PCAT)

The three-year curriculum in high-yield outpatient general internal medicine topics taught through innovative and engaging methods on Tuesday mornings and Friday afternoons for a total of three hours per +1 week. 

Practice Based Learning & Improvement (PBLI)

This clinic-based curriculum is designed to help residents develop mastery in the management of a portfolio of important chronic illnesses in primary care. Faculty facilitators provide up-to-date guideline recommendations and review relevant clinic resources.  Residents then use illness-specific registry reports, identifying patients with the targeted illnesses, and an array of relevant data to highlight care gaps. They engage in proactive planning, setting of chart reminders, and outreach to patients, with a goal to close gaps in care. This curriculum encourages residents to take pride in their work as primary care providers, reinforces learning through direct patient care, and enables residents to be conscientious stewards in their patients’ care. It reviews many of the QI/PS skills learned in WISC and encourages involvement in clinic-wide and individual improvement projects.

Ambulatory Report

Viewed by many as the capstone conference to clinic week, 12-15 residents and a primary care faculty facilitator meet to share cases that have piqued their curiosity, taught them new clinical skills, led to exciting outcomes or, simply, remain puzzling. This conference is informal and involves peer teaching and camaraderie, real-time literature searches and guideline review, and application of knowledge and skills from other didactics to real-time patient care. It is also a time for check-in on how clinic is going and for updates on clinic processes.    

Wellness and Improvement Science Curriculum for Interns (WISC)

WISC is a longitudinal Improvement Science curriculum delivered during intern year. This innovative curriculum combines the topic and tools of quality improvement and patient safety (QI/PS) with the skills needed to increase resilience, reduce burnout and promote wellbeing. By combining QI/PS and Wellbeing concepts, our interns develop a greater appreciation of health systems science, and are prepared for becoming not only well-rounded, productive, and happy physicians, but also change agents.

Ambulatory Residency Advisory Committee (Ambul RAC)

This committee meets 1st and 3rd Thursdays at noon and is made up of interested residents, a chief resident, continuity clinic directors, and rotation directors and educators to a) coordinate logistics and actions of the three Primary Care Continuity Clinics (OHSU, VA, Old Town Clinic) as well as the Kaiser rotation and additional ambulatory rotations, and b) serves as the Outpatient Curriculum Committee which evaluates and helps coordinate all seminars in the +1 week. 

Ambulatory Editorial Board Resident Steering Committee

This steering committee provides guidance to faculty members teaching in the 3-year high-yield Primary Care Ambulatory Topics. Participation on the Editorial Board Steering Committee provides residents with longitudinal, dedicated time, to participate in ambulatory curricular design and continuous process improvement. It is an opportunity to participate as a resident leader in education and the development of ambulatory curricula.

Additional Outpatient Rotations

IM - Blue Firm Ambulatory

Goals

  • To increase your knowledge of the nature and extent of health disparities and health system gaps in our community and country.
  • To increase your sociocultural awareness and expand your appreciation for the impact of the social determinants of health.
  • To improve knowledge, skills and attitudes toward indigent health and health care through exposure to clinical practice and relationships in a safety net clinic.
  • To provide you with the skills and capacity to feel empowered to address health care for indigent/unstably supported individuals and to address health system and social system gaps that these individuals encounter.
  • To better understand addiction and addiction treatment options.
  • To allow you to have additional continuity clinics on a weekly fashion.

Overview

Each intern completes the three-week social medicine rotation. This rotation is composed of clinical and non-clinical experiences at a variety of sites serving vulnerable patients within the Portland community and “off the hill” (aka not at the VA or OHSU). This rotation includes Home-Based Primary Care visits to patient homes, a Narrative Medicine activity with one of your patients, volunteering opportunity in your new community, and Advocacy project and didactics lead by the chief residents, perspective-taking opportunities through a variety of experiential activities, Art in Medicine as a way of exploring patient-centered care, and a closer look at the role of race in the health of our patients, communities and population.

2020 Kaiser Didactics

In the second and third years, residents rotate with the ambulatory clinics in the local Kaiser Permanente in the Portland area. The two month rotation is an opportunity to experience both primary care and ambulatory specialty care in a large non-government integrated HMO setting, different from experiences at the VA and the University. Residents are given increasing levels of autonomy in management of outpatient cases in the primary care clinics where they enjoy continuity with a small group of physician preceptors. Residents are able to express a preference in their subspecialty experiences including cardiology, pulmonology, neurology, urology, nephrology, oncology, physiatry, and gynecology. A week in the urgent care clinic provides further opportunity for procedures like suturing and injections as well as management of acute injuries. Third year residents are also given an option for a two week hospitalist rotation as an opportunity to contrast experiences at the VA and the University.

The rotation includes two conference series. The first of these is the Health System Curriculum, a collection of topics relevant to current ambulatory practice such as healthcare economics, current government legislation, advanced care planning, Death with Dignity, quality improvement projects in practice, and personal financial wellness. The second conference series includes topics relevant to the current practice of primary care such as headache management, chronic kidney disease, recreational use of marijuana, diet and weight loss. With only eight residents per rotation block, these conferences are conducted as small groups, allowing for engaged learning. Within this small group, residents share ambulatory case presentations and discuss medicine in the lay media.

Finally, the third year residents complete a self-designed and self-directed independent investigation or quality improvement project over the course of the rotation. This is often a highlight of the rotation. Recent topics have included: the impact of temperature screening on identifying asymptomatic COVID-19 cases on presentation to the primary care clinic, the role of architecture on healing in the hospital setting in Portland vs Kenya, and means of incorporating advocacy training into residency curriculum.

The Kaiser rotation is frequently described as a unique and novel ambulatory experience that allows residents to visualize outpatient practice in a different way. Over the last few decades, many of our graduates choose to work at Kaiser after residency – and many of them choose to teach and precept our OHSU Internal Medicine residents.