Ambulatory Training

Interns have a minimum of 14 weeks of ambulatory time that is composed of three 2-week Intern Immersion Blocks at their continuity site, two weeks on an outpatient cardiology/pulmonary selective, four weeks on a predominantly outpatient geriatrics rotation through the West Haven VA geriatrics program, and two weeks in the Yale New Haven Hospital emergency room.  In addition, many of the traditionally “inpatient” rotations such as the Oncology service, Advanced Clinical Experience in Geriatrics service and Peter’s Renal service have integrated outpatient clinical sessions.  The three continuity site Immersion Blocks include weekly continuity clinics, urgent care, an in-depth psychosocial curriculum, rotations through several core outpatient specialty clinics either on-site or at local outpatient offices, and participation in our celebrated Ambulatory Friday curriculum. Outpatient subspecialty offerings during these blocks include our on-site dermatology and diabetes clinics, addiction medicine at the local methadone maintenance center, women’s health at Planned Parenthood, otolaryngology and podiatric medicine at local affiliated private practice sites, and our own warfarin anticoagulation clinic.  Described in more detail elsewhere, the intern psychosocial curriculum is a cornerstone of the Yale Primary Care Program and includes a psychiatry consult clinic, behavior change clinic, and a medical interviewing practicum that includes review of videotaped patient encounters.  Lastly, our Immersion Blocks feature a novel interactive curriculum co-authored by faculty and senior residents in 2012 that is designed to cultivate the Systems-Based Practice core competency prescribed by the ABIM.  This self-directed workbook bolsters interns’ knowledge of their continuity practice site, exposes them to the logistics of accessing the local resources available for our underserved patients, and builds upon essential outpatient medicine skills such as billing and coding, procedure documentation, and navigating our evolving health care system. Interns are required to develop and implement a practice innovation at their training site by the end of their third Immersion block.  Intentionally, all interns benefit from their first Immersion block within the first four rotations of intern year to assure that they are developing proficiency at their continuity site.
The two week intern cardiology/pulmonary selective boasts foundational experiences at two premier subspecialty practices with one-on-one teaching and hands-on exposure to the full breadth of outpatient cardiac and pulmonary testing.

Second year residents spend a minimum of 16 weeks devoted to ambulatory training. This includes a total of 14 weeks in dedicated ambulatory block rotations and at least 2 weeks of elective. Residents may select ambulatory settings for all 8 weeks of scheduled elective bringing the ambulatory training to 22 weeks. In addition, the required neurology and non-CCU cardiology rotations during the PGY-II year incorporate both hospital-based and outpatient-based experiences.

The ambulatory block rotations for PGY-II residents include one 6-week rotation in a community primary care teaching practice, one 6-week rotation that includes continuity clinic sessions and several specialty clinics as described below, and a 2-week rotation focused on quality-improvement and systems-based practice. While on the ambulatory specialty block, residents have two continuity practice sessions weekly, participate in our diabetes disease management, joint injection, and dermatology clinics and attend specialty practices of their choosing to round out the experience. The two-week quality-improvement rotation occurs in the first half of the PGY 2 year and is an opportunity for residents to do a comprehensive review of their own panel of patients, identify an area where they can improve processes of care and develop an intervention. As noted below, there is a structured opportunity in the PGY-III year to assess the effectiveness of this intervention.

While on ambulatory block, residents maintain their weekly continuity clinic.  In addition, all of the residents on ambulatory block convene on Fridays for our dedicated ambulatory medicine curriculum, which includes lectures, interactive seminars, peer teaching, self-directed learning, workshops, and off-site experiences.