General Information

Current trends point toward shorter and fewer hospitalizations for patients and greater emphasis on outpatient care and case management services. The goal of the Clinic Block Rotation is to increase residents’ exposure to their continuity clinics’ services, functions and personnel. This will help R1’s and R2’s develop a comfortable platform of knowledge to assure a successful three-year outpatient continuity clinic experience and will help R3’s prepare for future practice in ambulatory care.

In the R1 and again in the R2 year, each resident will spend one four week block doing five half days of clinic at their continuity clinic. The other five half days will be spent in individual and small group activities and case conferences related to the continuity clinic experience.  During the R3 year, each resident will spend a number of one to two week blocks working seven half days of clinic in their continuity clinics. They will be seeing up to three to four patients per hour and will have one to two half days of administrative time for patient follow-up, consultation, reading, research, and preparation for teaching R2’s and R1’s during didactics and case conferences.

Orientation and Supervision

The Clinic Block Rotation will be introduced briefly during the R1 Orientation at each continuity clinic site. At the beginning of each R1’s Clinic Month the resident will arrange to meet with their Clinic Chief or a faculty preceptor at their continuity clinic for a more detailed orientation of the block activities. This orientation will include introducing the resident to the clinic staff members.  During the block residents will have the opportunity to spend more time with these staff members to accomplish the goals listed in the Clinic Block Checklist.  Either the Clinic Chief or the preceptor of the day will act as a day-to-day point person if any questions or problems arise during the month. The resident’s advisor will be responsible for reviewing the block activities with the resident at their quarterly review using the Clinic Block Checklist.

Content Areas

Behavioral Sciences (clinic and individual activity – all three years)

Behavioral Science skills are an integral part of successful family practice and are taught throughout the three years of residency. During their Clinic Block each resident will have the opportunity to have one of the behavioral science faculty shadow them during at least one of their patient encounters, or videotape a patient encounter, and review the visit or videotape with the behavioral science faculty. This review session will address basic interviewing techniques and styles of interaction including both verbal and non-verbal communication with patients. Also addressed will be issues related to managing difficulty patients, making mental illness diagnoses, making mental health referrals and accessing other resources including co-counseling visits with the behavioral science faculty.

Laboratory Skills (clinic and individual activity – first year)

During their Clinic Block, each resident will work with the staff at their clinics in order to develop competency in performing and interpreting the following:

Each resident will also develop competency in:

• Phlebotomy

• Subcutaneous and IM administration of medications

• PPD testing

• IM immunizations

In addition, each resident will develop competency in obtaining samples and completing paper work for lab requisitions (and for obtaining the subsequent lab results) including STAT labs, order in advance and standing orders for:

• PAP and other pathology tests

• Cultures

• Urine tests

• Blood tests

Pharmacy (individual activity – first year)

During their Clinic Block, each resident will spend time at DFM Clinic's on site pharmacy. They will learn about the role of the on-site pharmacy, formularies for various health insurance plans including Medicaid, and procedures for procuring medications for under and uninsured patients.

Clinic Systems (individual activity – first year)

Residents need to develop a clear understanding of their clinics’ organizational systems. During their Clinic Block they will spend time getting to know their clinic staff and their jobs and responsibilities including:

• Medical Director 

• Clinic Manager/Coordinator - becoming familiar with general management of a medical clinic, patient flow, etc.

• Front Desk Staff – Telephone Receptionists, Receptionists, Schedulers, etc.

• Back Office Staff – Billing, QCP, etc. (a coding workshop will be done as a small group activity at SFM for residents from all three sites)

• Triage Staff – Triage Assistants, Triage Nurses, etc.

• Nursing Staff

• Social Work Staff

• OB Coordinator (or Clinic Chief) - learning how OB patients are assigned, etc.

• Referral Staff (or Clinic Chief) – learning how to fill out forms, how to find specialists and other community resources, etc. (working with interpreters and cross cultural issues will be done as a small group activity at SFM)

• Insurance Screeners - becoming familiar with the various insurance plans their clinics accept, how to find covered services, formularies, etc.

• Financial Screeners - learning how they determining eligibility for sliding scale care, enrolling patients in BCHP, BHP of Washington, CHIP, First Steps, Medicare, Medicaid and SSI and accessing community resources for uninsured and underinsured and low income patients.

Medical Records (clinic and individual activity – first year)

Accurate documentation of all patient encounters and information is critical to good patient care. During their Clinic Block residents will become familiar with their clinics’:

• Medical charts – chart layout including problem and medication lists, flow sheets, lab results, consults, etc.

• Flow sheets for chronic problems as well as health care maintenance.

• Paper medical record system – finding charts, returning charts, filing charts, etc.

Or

• Electronic health records system

• OB chart system – finding charts, returning charts, filing charts

• Dictation and use of templates

• Triage forms - how to fill them out completely and accurately

Computers (clinic and individual activity – all three years)

Computers play an increasingly important role in medical data management. During the Clinic Blocks residents will learn to master:

• Internet resources including doing literature searches via the University of Washington links and Swedish intranet links

• EMR (Electronic Medical Records)

• PDA (Personal digital assistant) use including logging procedures

Patient Education (clinic and small group activity – all three years)

Patient education is an essential part of every patient encounter and includes such issues as teaching patients how to care for themselves while ill, how to take their medications, and how to prevent illness and injury. During their Clinic Blocks residents will become familiar with and be able to access and utilize written patient information, including patient handouts in the exam rooms, in clinic files, in residency developed computer folders and on the Internet.

R2 Specific Activities (clinic and individual activities)

During their R2 Clinic Block residents will build on the skills above as well as learn additional procedural skills. There will also be a greater emphasis during the R2 year on the community context of care. These skills and activities will include:

• X-ray techniques

• OB ultrasound

• NST’s

• Home visits

• Nursing home care

• Public health nursing

• Maternity support services

• Shelter care

• 45^th St. Youth Clinic

Clinic Block Schedules

The Clinic Blocks for R1’s and R2’s will be scheduled during the first five blocks of each academic year. Four to six residents will be scheduled during the same block and will all meet together for Thursday Workshops and Friday Case Conferences.  The Clinic blocks for R3’s will be scheduled throughout the year.  R3’s do not have Thursday Workshops but do participate in Friday Case Conferences on a volunteer basis and act as teachers and consultants to R1’s and R2’s at these conferences.

(R3) – Third year residents will be scheduled in clinic in blocks of one to two weeks depending on their schedule as FP Service Chief and during specialty rotations where they are paired with another third year resident.

(R2, R1) – At the satellite clinics, first and second year residents will be scheduled in their continuity clinics during the months when there is the most space available.

R1 Clinic Block

Clinic – R1’s will see 3 patients per half day for two weeks, then 4 patients per half day. Each clinic will need to be creative in scheduling the extra clinics for R1’s by scheduling R3’s in rotations where they will be in clinic fewer days.

Group activities - Thursdays from 1:30 to 5:00 PM at SFM

1. Coding - Residency Faculty

2. Using interpreters and cultural competency - Outside Faculty

3. Basic Suturing Techniques - Residency Faculty

4. Planning for community medicine projects - Residency Faculty

5. Patient education and behavioral change - Residency Faculty

Case conferences – Friday from 1:30 to 5:00 PM at SFM

• Conferences will be coordinated and taught by an R3.  Each R3 will have this opportunity for two weeks during their R3 year.

• Also attending the conference, as consultants, will be a family practice faculty and at least every other week a behavioral science faculty.

• Cases seen by residents during their outpatient clinics the preceding week will be discussed using the Case Conference Template as a reminder to cover all aspects of the patient visit.

• Residents doing the Clinic Block will let the R3 and faculty as well as the other residents doing their Clinic Block, know which cases they want to discuss by Wednesday afternoon to give the R3 and faculty time to prepare teaching materials for the conference.

• In order to cover a variety of the most common problems seen in primary care, an attempt will be made to cover as many of the following as possible.  Each week three or four of the topics listed below will be covered:

Clinic Specific Activities

During the Clinic Block there will be approximately 24 hours devoted to these activities. Times below are approximate. It will be up to the resident to make sure that these activities are completed and signed by the person involved in teaching. When appropriate, these should be competency-based.

• Behavioral Science - shadowing and review (1.5 hours)

• Laboratory Skills (3 - 5 hours)

• Pharmacy (2 hours)

• Clinic Systems (4-6 hours)

• Medical Records (1 hour)

• Computers (1.5 hours)

• Dictation and charting (2.5 hours each week)

R2 Clinic Block  

Clinic – R2’s will see 5 to 7 patients per half day. Each clinic will need to be creative in scheduling the extra clinics for R2’s by scheduling R3’s on rotations where they are in clinic fewer days.

Group activities – Thursday from 1:30 to 5 PM at SFM

• Advanced coding workshop - Residency Faculty

• Hospital Procedures and OB Ultrasound - Residency Faculty

• Behavioral Science – Behavioral Science Faculty

• Evidence-based Medicine – Residency Faculty

Case conferences – see R1 Clinic Block  

Clinic Specific Activities Times below are approximate. It will be up to the resident to make sure that these activities are checked off and signed by the person involved in teaching.

R3 Clinic Blocks

Clinic – R3’s will see 8 – 10 patients per half day. Each clinic will need to be creative in scheduling the extra clinics for R3’s by pairing the R3 on their continuity clinic rotation with a fellow R3 who is away, doing VA, FP Service, CCU or a focused specialty rotation.

Administrative time includes: Charting, patient follow-up, consulting, reading, chart reviews for chronic disease management, acting as ‘Preceptor for the day’, preparing presentations for didactics or case conferences, research for R3 talks, etc.

Goals  


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