In previous years, categorical medicine residents at the University of California at San Francisco (UCSF) spent 2 months each year on an ambulatory block. There was no clear distinction between the goals and objectives for each year and no coordination between inpatient and outpatient didactics, resulting in duplication and omissions. The rotation director struggled to identify appropriate clinical opportunities for the house staff, who felt that the rotation lacked educational value and lacked opportunities to improve their clinical skills. The static nature of the categorical rotation was often contrasted to the successful ambulatory block curriculum created for the primary care residents at UCSF that was almost uniformly rated by the residents as having high educational value ().
Summary Rotation Evaluation Scores by Primary Care Residents on Ambulatory Block
Two years ago, we restructured the outpatient experience for the categorical residents into a 3-year curriculum with distinct goals and objectives for each year of training and clinical experiences and didactic sessions to achieve these goals (Appendix A
). We initially reviewed anonymous comments made by the house staff after completing the rotation. We subsequently conducted focus groups with residents interested in participating in curricular redesign, and we invited them to share their frustrations and suggestions. We then discussed our ideas with other UCSF program directors to elicit their input and to coordinate with their own rotations. Finally, we met with our Chair, who concurred with our approach and who provided additional support in identifying generalist and subspecialty faculty to assist with the new rotation.
During the first year, all PGY1 residents spend 1 month on an ambulatory care rotation and 1 month on a subspecialty elective. During the ambulatory month, they focus on general outpatient internal medicine and geriatrics. The general medicine didactic series provides instruction in aspects of physical examination, interviewing skills, and introductory tools of evidence-based medicine. The didactics are supplemented with a written syllabus. The geriatrics experience exposes the residents to the various practice settings of geriatric medicine, including home visits, senior centers, nursing homes, and hospice care.
To help residents make a decision about subspecialty choice, residents are given the opportunity to select a subspecialty elective during the second half of the year. This elective can have either an outpatient or an inpatient focus; it allows the interns to have early exposure to a subspecialty of interest and assists them in making informed decisions about career choices.
During the second year, each resident spends time on the subspecialty medicine outpatient block. In order to improve continuity, access to clinics, and didactic teaching, the block was increased to 3 contiguous months. The goal of this block is to provide clinical and didactic training in 8 core medicine subspecialties. Residents spend 4 half-days each week in outpatient subspecialty clinics. This schedule increases their exposure to subspecialty faculty, thereby broadening their understanding of a given subspecialty and facilitating career guidance and research opportunities. Didactic sessions are presented in all 8 subspecialty areas during 6 hours (2 half-days) of lectures and seminars per week. Topics are chosen with the input of division chiefs, fellowship program directors, and general medicine faculty to emphasize critical topics in outpatient subspecialty medicine. Emphasis is placed on subjects that are not covered in inpatient conferences or that are better suited for small-group case-based discussion. The didactic seminars are supplemented by a written syllabus that includes pertinent articles and summaries of didactic sessions. In addition, each resident spends 2 half-days in his/her regular continuity clinic and 1 half-day in an urgent care setting.
Another important objective of the second-year block is to promote scholarly activities. Each resident is expected to begin a broadly defined scholarly project and is given 1 half-day of protected time each week to initiate work on his/her project. Additionally, each resident is required to lead a discussion during a weekly journal club session and to teach an electrocardiogram didactic session to the other ambulatory residents. Finally, each second-year resident participates in a program to improve his/her teaching skills. This 3-month block also provides prolonged exposure to both generalist and subspecialty faculty and to fellow residents, allowing for mentoring, and fostering a supportive atmosphere in a large program.
During the third year, residents spend 2 months on an advanced ambulatory rotation. The focus of this rotation is to learn outpatient skills in nonmedical subspecialties and specialized areas of internal medicine such as women's health, dermatology, neurology, and the surgical subspecialties that are often missing from other parts of the curriculum. The didactic sessions are based on these core topics. Additionally, residents participate in an adolescent medicine clinic and receive didactic teaching in adolescent medicine topics. The overall goal of the block is to provide a well-rounded outpatient medicine experience for graduating internists. The third-year residents are also allowed a significant amount of flexibility in selecting their clinics to allow them to pursue their specific interests. Finally, residents are encouraged to continue scholarly work and are again provided with protected academic time during the block months.
illustrates typical schedules in all 3 years.