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:
- Deliver high quality, evidence-based, comprehensive primary care to a panel of patients
- Appreciate how to navigate a complex medical system and work within a multidisciplinary team to coordinate the care of their patients
- Develop the knowledge and skills required to diagnose and manage the most common ambulatory clinical conditions and preventive care needs of their patients
- Gain experience in a community-based ambulatory setting that will supplement their continuity clinic experience and specifically prepare them for their intended career pathway
In addition to Ambulatory Block and QICC rotations, our ambulatory curriculum is broken down into three main components: 1) the continuity clinic experience, 2) a common ambulatory curriculum, and 3) 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.
Continuity Clinic Experience
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 unit 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!
Center for Primary Care
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, with approximately 85% of patients being either uninsured or on public insurance. The population is diverse, including refugees and a large number of patients (approximately 40%) speak a language other than English. The CPC uses a team approach to provide comprehensive care to patients utilizing social workers, clinical pharmacists, diabetes educators, nutritionists, RNs, LPNs, nurse care managers, and onsite Spanish interpreters, and additional resources including onsite psychiatry and specialty care and an onsite laboratory. Residents with their continuity clinic at the CPC can participate in a multidisciplinary 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 Women’s 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 RN, LPs, MAs, as well as social work, pharmacy, nurse case manager and psychiatry liaison support. The Fain has additional services which include diabetes management team, HTN clinic, and complex care team, and many of the providers can perform procedures such as joint injections/aspirations and biopsies onsite with residents. The clinic preceptors are primarily full time 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 ranging in age from 20 to 100. It is divided into several teams comprised of the Primary Care Provider, Clinic Nurse, Clinic LPN, medical assistants, Social Worker, Nutritionist 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.
Common Ambulatory Curriculum
In addition to continuity clinic, all residents will participate in the following components of the ambulatory curriculum.
Community-Based Site: The combination of continuity clinic and a second community-based site forms a unique ambulatory immersion day that occurs weekly starting in the PGY2 year when residents start at their “Second Site” clinic for a half day each week on the same say as their continuity 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. Second Site is designed to complement the continuity clinic experience and broaden residents’ ambulatory exposure. Each resident will be paired in a one-on-one relationship with a faculty member based on the resident’s area of interest. Faculty members are carefully selected based on their interest and teaching abilities. Training sites have included private offices around Providence and nearby communities, Providence Ambulatory Health Center Network (a nationally recognized consortium of neighborhood health centers), VA Firm clinics, Brown Student Health Services, as well as selected subspecialty office practices. Second Site has been one of the most popular rotations 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 or a letter of recommendation. Additional details on core curricular elements are included below.
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.
Ambulatory Noon Conference
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.
Additional Clinic Experiences
Brown offers a variety of additional ambulatory clinical experiences in which residents can elect to participate while on intern QICC, ambulatory block, or elective rotations. 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).
Women's Health Clinic
Women’s Health Clinic is a weekly half-day clinic focusing on women’s health consultations and procedures from within our primary care practice such as abnormal uterine bleeding, family planning, breast complaints, and menopause. We aim to expand this opportunity to interested learners in the 2020-2021 year.
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).
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.
Homeless Outreach Clinic
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. Residents will work with a multidisciplinary team including an attending, addiction fellow, social worker, pharmacist, program coordinator and community health worker in Recovery Clinic. Over the past several years we have been able to provide DATA waiver training to our intern classes to allow them to prescribe buprenorphine. Participation in the Recovery Clinic allows residents to put this training into action under the tutelage of an experienced faculty member.