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The majority of healthcare in the United States occurs in the ambulatory setting and most residency graduates will have careers involving an ambulatory component regardless of whether they choose a specialist or generalist career pathway. Our ambulatory curriculum is therefore designed to create a strong foundation in ambulatory medicine and to provide our residents with the skills necessary to be successful ambulatory clinicians and leaders regardless of their intended career choice. The goals of the ambulatory curriculum are to prepare residents to:
In addition to Ambulatory Block and Quality Improvement Continuity Clinic (QICC) rotations, our ambulatory curriculum is broken down into three main components: 1) the continuity clinic experience, 2) community-based teaching experience (second site clinic), 3) a common ambulatory curriculum, and 4) additional clinical experiences in which residents can elect to participate. Please explore a brief sampling of what Brown has to offer in each of these areas in more detail below.
Residents’ continuity clinic starts during July of intern year and forms the foundation for their ambulatory clinical experience. Residents see patients weekly in their continuity clinic except when on vacation, night float, and ICU rotations and more frequently when on several of their core ambulatory rotations. Brown offers three sites for continuity clinic. Each site provides residents with the opportunity to manage a panel of patients under the mentorship of experienced internal medicine physicians. Additionally, each site has an electronic medical record system that allows residents access to data on their practice patterns, quality metrics, and patient outcomes. Each clinic site includes unique opportunities for our residents!
The Center for Primary Care (CPC) is located a short 1.5 miles from RIH and is the largest of our continuity clinic sites. The CPC is a Patient-Centered Medical Home and a safety net clinic for patients in the surrounding neighborhood. We care for a population of patients ages 19 and older, with approximately 80% of patients being either on public insurance of uninsured. The population is racially, ethnically, and linguistically diverse, with over 60 languages represented. The CPC uses a team-based approach to provide comprehensive care to patients utilizing medical assistants, social workers, clinical pharmacists, diabetes educators, nutritionists, RNs, LPNs, nurse care managers, community health workers, and onsite Spanish interpreters. Additional resources include onsite psychiatry, onsite specialty care, an onsite laboratory, and a unique team trained to help patients with social determinants of health. Residents with their continuity clinic at the CPC can participate in an interdisciplinary comprehensive care clinic to help care for their most complex patients. The CPC is also home to various other clinical teaching opportunities including Recovery Clinic, Transitions Clinic, Procedure Clinic, Refugee Clinic, and the Reproductive and Gender Health Clinic which are available to any residents.
The Primary Care Clinic located at The Miriam Hospital is located at the Fain Ambulatory center on the Miriam Hospital Campus. The Fain clinic is a Patient Centered Medical Home and primarily serves the Central Falls/ Pawtucket area. Approximately 40% of patients are non-English speaking and 60% have Medicare, Medicaid, or other state supported insurance. Clinic staff includes Drs. Christine Duffy and Cathleen Whelan as well as several RN, Medical Assistants, a social worker, a pharmacist, a nurse case manager, and psychiatrist liaison. The Fain has additional resources for patients such as a diabetes management team, a HTN clinic, and a complex care team. The clinic also has a procedures clinic which residents can attend and perform procedures such as joint injections/aspirations and biopsies. The clinic preceptors are primarily full time community-based PCPs with extensive experience in the outpatient setting.
The Providence VA Primary Care Clinic is a patient-centered medical home responsible for almost 20,000 Veterans. It is divided into several teams comprised of the Primary Care Provider, Clinic Nurse, Clinic LPN, medical assistants, Social Worker, Nutritionist, Clinical Pharmacist, and Mental Health Provider who work together to improve patient access to care with a focus on chronic disease prevention and management. Residents will have the opportunity to care for both men and women who have served this county, many of whom have disabilities related to their military service. Residents are responsible for complex patients under the supervision of an assigned preceptor for the entire three years. In addition to the routine face-to face and telephone appointments, the VA has a sophisticated scheduling and video conferencing system for patients and their caregivers through a special portal. Residents will have the opportunity to care for their patient panel during clinic and between clinic visits through a remote portal that can be conveniently accessed from their home computer.
During the Junior and Senior years, residents spend an additional half day per week in another site, designed to complement their continuity clinics and broaden the residents’ ambulatory exposure. Faculty volunteers are carefully selected for this effort based upon their interests and teaching abilities. Residents and community-based faculty are carefully paired in a one-on-one, longitudinal relationship based on each resident’s identified area of interest. Training sites include private offices around Providence and nearby communities, Providence Ambulatory Health Center Network (a nationally recognized consortium of neighborhood health centers), the VA Firm clinics, Brown Student Health Services, as well as selected subspecialty office practices. Second Site has been one of the most popular clinical experiences for our residents and has been a wonderful opportunity for residents to work with a faculty member in a longitudinal relationship that can also result in research partnerships, career mentorship, or a letter of recommendation.
The combination of a half day in continuity clinic and a half day in second site forms a unique ambulatory immersion day that occurs weekly starting in the PGY2 year when residents start at their second site clinic. Residents who are on wards will have a Day Float resident covering their team so that they can focus their entire attention for that day on their ambulatory learning.
In addition to continuity clinic, all residents will participate in the following components of the ambulatory curriculum.
Faculty members at all three clinic sites present a topic weekly prior to each continuity clinic session. Presentations are created by residents and are curated by Brown faculty in order to ensure they are high quality, participatory, and highly relevant to our residents, and cover topics relevant to ambulatory medicine. Topics include how to manage various ambulatory conditions, review of quality metrics and how to manage a panel of patients, and introductions to various aspects of systems-based care.
Every month we present an ambulatory topic during noon conference at each of our three hospitals. These ambulatory noon conferences supplement the material presented during pre-clinic conference and include material presented by both our DGIM faculty and our specialist colleagues.
All residents will participate in several core rotations that feature a combination of didactics focused on ambulatory education and a more immersive experience in residents’ continuity clinics. These rotations include the intern Quality Improvement Continuity Clinic (intern QICC) rotation, the PGY2 Quality Improvement Continuity Clinic (QICC) rotation, and Ambulatory Block rotations in the PGY2 and PGY3 years. Interns will also participate in a new two-week ambulatory endocrinology experience.
Brown offers a variety of additional ambulatory clinical experiences in which residents can elect to participate while on ambulatory rotations and electives. Listed below is just a sampling of some of the experiences available to residents:
Procedure Clinic is an opportunity for residents to learn how to provide common office-based primary care procedures. Our most commonly requested procedures are orthopedic corticosteroid injections (E.g. knee joint, subacromial shoulder, trochanteric bursitis, trigger finger, deQuervain’s tenosynovitis), family planning procedures (E.g. Nexplanon insert/removals, IUD insert/removals) and occasional dermatologic procedures (E.g. I&Ds, skin tags, biopsies, toenail removals).
Our Reproductive and Gender Health Clinic is a weekly half-day clinic focusing on women’s health consultations, gender affiriming care, and reproductive health procedures.
Historically Rhode Island has been a resettlement hub for many refugee families. Our Refugee Clinic performs an initial refugee health assessment visit within a month of the new refugee’s arrival and is a great opportunity for residents interested in refugee health, global health, primary care and infectious disease. Many of these patients elect to continue receiving their primary care at the Center for Primary Care (CPC). Our refugee clinic has been very busy recently with the arrival of refugees from Afghanistan.
The Transitions Clinic program provides a variety of coordinated medical and social services for formerly-incarcerated patients. These are patients who tend to be some of the sickest and most indigent patients in Rhode Island and for whom continuity of care outside of the prison setting is necessary to sustain health and increase access to care. Care is delivered through an innovative multidisciplinary team including Community Health Workers with special attention to addressing the social determinants of health.
The Center for Primary Care partners with House of Hope to deliver medical services to patients experiencing homelessness. Medical providers see patients in an exam room on a mobile van that also provides outreach, social services, and showers to homeless patients in the community.
The Recovery Clinic at the Center for Primary Care provides coordinated office-based opioid treatment and social services for patients who are in recovery from opioid use disorder and other substance use disorders. Residents will work with a multidisciplinary team including an attending, addiction fellow, social worker, pharmacist, program coordinator and community health worker in Recovery Clinic.