Intern Ambulatory Program

Outpatient continuity practice experience at Beth Israel Deaconess Medical Center begins at the start of the internship year. Each intern is assigned to a co-management preceptor who supervises the house officer during clinic; serves as a clinical resource; reviews all labs and co-signs notes; reviews and provides advice on documentation and billing; and offers formal, written feedback twice a year. A half-day, "hands-on" orientation to the entire ambulatory practice system occurs as part of the overall residency program orientation.

During their first year, interns are scheduled for four weeks of block time in ambulatory care. The primary goals are: (1) to help interns master the diagnosis and treatment of common ambulatory medical problems, and(2) to learn how to modify disease risk factors by counseling to achieve behavioral change. The core of the rotation consists of meaningful, continuity clinical experiences coupled with a curriculum that focuses on common diseases associated with outpatient medicine. In addition, each intern hones their skills in treating the elderly through scheduled nursing home practice sessions. The rotation is designed to allow the interns to further build their patient panels, become familiar with the various ambulatory practice systems, gain experience with office-based procedures, and participate in a curriculum covering a spectrum of important ambulatory topics. These include:

Practice System Topics

Coding and Documentation, On-Line Medical Record, Patient Education Resources, Primary Care Case Conference, The Role of Community Resources and Social Work, Time Management

Core Ambulatory Topics

Back Pain, Breast Examination, Chronic Cough and Asthma, Common Infections, Diabetes Mellitus, Headache, Hypertension, HIV Primary Care, Pap Smears, Pelvic Exam, Periodic Health Exam, Somatization, and STDs.

Junior & Senior Resident Ambulatory Program

The ambulatory care experience for all junior and senior residents includes:

  • Weekly continuity clinic
  • Multi-disciplinary support staff
  • Mentoring relationship with a single preceptor
  • Three-week ambulatory block rotations
  • Exposure to an ambulatory medicine curriculum
  • Ambulatory elective experience chosen from a vast array of subspecialty clinics and community-based settings
  • An optional primary care track

The Primary Care Track

The primary care program at BIDMC was established in 1973. Elective participation in the program begins at the start of the junior year. Each primary care resident has two weekly continuity clinic sessions; increased ambulatory block time (5 blocks vs. 3 blocks for non-primary care residents in each of the JAR and SAR years); expanded ambulatory elective opportunities; exposure to a comprehensive primary care curriculum; and establishment of a close mentoring relationship with a general internal medicine faculty member. Primary care residents are encouraged to choose an area of concentration in primary care during their senior year. One of the primary care residents' weekly continuity clinic sessions is held off-campus at a local area community health center, private practice, student health center, hospice, geriatric settings or the VA medical center.

The Junior and Senior Ambulatory Core Curriculum

The junior and senior ambulatory core curriculum addresses the knowledge, skills and attitudes that internists must attain to become competent practicing physicians. The curriculum is presented through an organized didactic program including conferences, lectures, and case studies scheduled during three-week long ambulatory block rotations. General internal medicine faculty members, BIDMC subspecialists, and senior housestaff serve as seminar leaders, lecturers and discussion facilitators.

The ambulatory curriculum is presented at the following educational forums:

Ambulatory Care Conference

The Ambulatory Care Conference is a weekly lecture series focusing on topics pertinent to the practice of outpatient medicine. Discussion centers on concepts and understanding of disease management, and treatment options. Speakers include general internal medicine faculty as well as various BIDMC subspecialists.

Ambulatory Curriculum Conference

The ambulatory didactic conference provides a foundation of core concepts relevant to the practice of general internal medicine and includes topics in medical orthopedics, women's health, geriatrics, and complementary medicine, to name but just a few.

Preventive Medicine Series

The preventive medicine series focuses on principles of maintaining health and preventing disease, disability, and death. The basic components of the preventive medicine series include biostatistical principles and methodology; epidemiological principles; recognition and control of environmental and occupational hazards; social, cultural, and behavioral factors in medicine; and application of preventive principles and outcome measures in clinical practice. Conferences are interactive and include a critical appraisal of the literature as well as analysis of the utility of screening for specific disease entities.

Behavioral Medicine Series

The Behavioral Medicine Series teaches internists about common behavioral health disorders. Emphasis is placed on learning methods of behavior modification, risk assessment, and risk modification. In addition, medical conditions and problems that raise attitudinal or difficult feelings for providers are presented and explored.

Brief Clinical Review

The Brief Clinical Review Series addresses common clinical issues in an evidence-based fashion.

Journal Club Curriculum

The HCA Journal Club Curriculum promotes evidence-based medicine and critical literature review in the resident's practice. The objective of the program is to study how clinical questions (such as diagnosis, prognosis, and treatment) are answered by solid scientific research involving populations or groups of patients. Participants learn to assess the validity of published evidence by understanding basic clinical research strategies, such as study design and statistical measurement, as well as gaining critical literature appraisal skills.

The following conferences and educational experiences supplement the core curriculum:

Resident-led Conferences

The resident-led conference series allows residents the opportunity to share their learning experiences in ambulatory medicine with their colleagues while developing their teaching skills. A designated resident chooses a topic from his/her assigned ambulatory elective to present at this conference.

Post-practice Conference

Post-Practice Conference takes place twice a week for residents while they are on their outpatient block rotation. It is led by the Primary Care Chief Resident and the attending of the month and includes a case-based approach to common problems in the outpatient setting.

Primary Care Career Development Series

This series provides residents interested in entering the field of primary care medicine the opportunity to receive guidance, information, and advice on how to approach and manage their own job search.

Ambulatory Educational Electives

The ambulatory electives are designed to provide residents with:

  • Opportunities to acquire diagnostic and therapeutic subspecialty care experiences occurring in the outpatient arena. Although each subspecialty elective experience varies, the objectives are the same: to expose the resident to patients with problems that may not be encountered in the inpatient and continuity venues and to provide the resident with a deeper understanding of selected diseases and conditions.
  • Opportunities to practice internal medicine in community-based setting and health care centers in order to gain further exposure to how internists manage the myriad of acute illnesses and exacerbations of common chronic disease with varying levels of health care resources. Community practitioners' offices and health care centers are particularly well suited for learning the important concepts of prevention, office management, population-based health care as well as how the patient's environment and sense of well being affects health and illness. Most compelling is the career-shaping opportunities the community physician offers in addition to the resident's experience with academic internists.

Assessment Of Ambulatory-Based Competencies

Assessment of the housestaff's clinical performance is a vital part of the ambulatory care residency training program. Through self-evaluation, observed clinical examination, formal feedback sessions, and continuous feedback delivery, the six core competencies as defined by the ACGME -- patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice-- are assessed for each individual resident.