Ambulatory Care

Over the past decade the practice of internal medicine has largely moved to the outpatient clinic. Most of the diagnostic work-ups can now be done in the outpatient clinic, and patients illnesses are followed in the outpatient setting. Many invasive specialities such as cardiology and gastroenterology can have their diagnostic procedures done as outpatients. Cardiac catheterization, insertion of permanent pacemakers, electrophysiology studies as well as all endoscopies and biopsies can be done through the outpatient setting. The American Board of Internal Medicine and various accrediting agencies are demanding that residency programs increase residents exposure to the ambulatory setting. Fifty percent of the ABIM certifying exam now comes from ambulatory care questions. In view of the above, the resident continuity clinic provides a challenging, rewarding experience.

The internal medicine resident continuity clinic experience is a strong vital part of the training program. Residents develop a strong personal and professional relationship with patients in their individual continuity clinics. The continuity clinic runs similar to a traditional internal medicine clinic in private practice with the advantage of board certified senior staff preceptors who are genuinely interested in resident supervision and teaching. To give you some idea - patients are placed into the residents clinics from a wide variety of venues (basically the same pool as for senior staff) which provides a broad, interesting, continuity clinic experience. The nursing and administrative support staff are the same as for senior staff. There is secretarial staff dedicated solely to the residents clinics. Results of lab, radiology reports, etc that residents order are expeditiously given to the residents for resident review, optimal patient care and education. There is a resident library and internet search access in the resident clinic. The continuity clinic experience is designed so that residents really are and feel that they are in charge of the care of their respective patients and the patients do identify the residents as their physician. Enthusiastic senior staff are always blocked out and available for checking out and teaching. All of the continuity clinics are centrally located in the same building complex as Scott & White hospital making for easy access when on hospital rotations at Scott & White.

Scott & White is fortunate that the largest portion of our business is in the outpatient setting. Through our large primary care network over one million outpatient visits occur each year. In addition to the continuity clinics, there is a month of general internal medicine clinic in the first year as well as the second year. All of the internal medicine residents rotate through outpatient subspeciality clinics in cardiology, gastroenterology, infectious disease, nephrology, dermatology and gynecology. Other areas that are becoming increasingly important in training primary care physicians such as orthopedics, ENT, physical medicine, etc. are also available for resident elective rotations. Depending upon how residents use elective time, they may spend as much as 40 percent of their residency training in the ambulatory setting. This is clearly one of the strongest advantages of a training program preparing people for the practice of medicine in the coming decade with a managed care environment.

An aspect of ambulatory care that has been implemented into the curriculum this past year are a series of small group sessions in the interns continuity clinics to develop interview skills. Expertise in the patient interview is one of the most important skills an outstanding internist needs. This addition to the curriculum is an asset for those house officers wishing to be the best internist possible.

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