Cooper Hospital Outpatient/Ambulatory Curriculum for Internal Medicine residency Prepared by Chief Residents Maya Pillai, Raquel Nahara and Vijay Rajput, program Director Objective: Residents will be able to diagnose and manage a wide range of important primary care health and disease states. Residents will understand the logistics of and work in a variety of practice environments. To learn comprehensive primary care medicine in an diverse ambulatory setting To learn how to manage acute complaints as well as patients with chronic disease on a long-term basis. To learn psychosocial issues of medicine (including cultural aspects of care, medical interviewing, psychiatric issues in primary care, substance abuse, and domestic violence) To learn “evidence based” medicine and apply them in clinical decision making as practice based learning To learn and apply preventative/screening measures To learn the “business” side of medicine, system based practice Graded Learning for each year • PGY 1 and PGY 2 will have their continuity ambulatory experience at 215, three cooper plaza office under supervision of Dr headly and Dr Comreci, assistant program directors. During these two years they will have indigenous patient care experience • PGY 3: The senior resident will choose satellite, General Internal medicine faulty practice as their continuity clinic and for their monthly block experience. This experience will enhance their understanding of private primary care office, they will learn front desk administrative and system based experience of primary care offices Objectives Patient Care and Medical Knowledge For each of the following primary complaints or illnesses: • Obtain an appropriate history and perform a focused physical exam to determine the most likely cause of each symptom. • Develop a diagnostic work-up for each complaint and likely diagnosis, balancing principles of evidence-based practice, cost effectiveness, and individual patient preference and values (the biopsychosocial model of health and disease). Acne Allergic rhinitis Alopecia Amenorrhea Anemia Ankle/foot pain/injury

Anxiety/Panic Disorder Arthritis Asthma and COPD Back pain Benign prostatic hypertrophy Breast mass Chest Pain Chronic pain syndromes Claudication Conjunctivitis/red eyes Constipation Coronary artery disease Cough Dementia and memory loss Depression Dermatitis (eczema, seborrhea, contact) Diabetes Diarrhea Dizziness / vertigo Dysfunctional uterine bleeding Dyspepsia Eating Disorders Edema Erectile dysfunction Falls Fatigue Fibromyalgia Gastroesophageal reflux disease Gout Headache Hematuria Hyperlipidemia Hypertension Incontinence Insomnia Irritable bowel syndrome Knee Pain/injury Lymphadenopathy Menopause Nephrolithiasis Neuropathy Obesity Obstructive sleep apnea Osteoporosis Palpitations and MVP Peptic ulcer disease

Pharyngitis] Proteinuria Pulmonary Module Sexually transmitted diseases Shoulder pain/injury Sinusitis Sleep disorders Somatization Syncope Thyroid nodule and disorders Upper respiratory infection Urinary tract infection Urticaria Vaginitis Weight loss For each of the following addictive behaviors, screen for use and abuse: • Alcohol abuse • Prescription drug abuse • Recreational drug abuse • Tobacco abuse (smoking and smokeless) For each of the following illnesses, counsel patients regarding the risks and benefits of screening: • Breast Cancer • Cervical Cancer • Colorectal Cancer • Prostate Cancer For each of the following preventative health measures, provide counseling about the latest recommendations: • Advanced directives / Living wills • Contraception • Cholesterol screening • Domestic Violence • Endocarditis Prophylaxis • Exercise/ Diet • Hormone replacement therapy • Immunizations for adults • Pre-natal counseling • Skin cancer identification / screening Demonstrate competency in the following procedural skills • Anoscopy • Arthrocentesis and injection • Clinical Breast Exam • Cryosurgery with liquid nitrogen • Digital Rectal Exam • EKG Interpretation

• Skin Biopsy – shave, excisional and/or punch • Pap & Pelvic Exam • Urinalysis • Vaginal Wet Prep Seek and apply the best available evidence to patient care. List the risk factors for the following primary care conditions: • Asthma and COPD • Breast cancer • Coronary artery disease • Cervical Cancer • Colorectal cancer • Depression • Diabetes • Gallbladder disease • Gastroesophageal reflux disease • HIV infection • Hypertension • Lung cancer • Obstructive sleep apnea • Osteoporosis • Peptic ulcer disease • Prostate Cancer • Thrombosis / Embolism Identify the most common causes of the following symptoms in ambulatory patients: • Abdominal pain • Anxiety • Chest pain • Constipation • Cough • Depressed mood • Diarrhea • Dizziness • Dyspnea • Edema • Fatigue • Fever • Headache • Hematochezia • Insomnia • Joint pain (hip, shoulder, knee, wrist, neck, low back) • Melena • Palpitations • Rash • Red eye

• Swollen joint • Syncope • Weight loss/gain For the following addictive illnesses, demonstrate appropriate knowledge of counseling skills and medical management options: • Alcohol abuse • Prescription drug abuse • Recreational drug abuse • Tobacco abuse (smoking and smokeless) For the following illnesses, demonstrate knowledge of current screening recommendations and understand areas of controversy: • Breast cancer • Cervical Cancer • Colorectal Cancer • Prostate Cancer For each of the following preventative health measures, know the latest management recommendations: • Advanced directives / Living wills • Contraception • Cholesterol screening • Domestic violence • Endocarditis Prophylaxis • Exercise/ Diet • Hormone replacement therapy • Immunizations for adults • Pre-natal counseling • Skin cancer identification/screening Practice Based Learning and Improvement Develop a willingness and ability to learn from errors and use them to improve individual practice and the health care delivery system. Develop answerable clinical questions from patient encounters, the answer to which will enhance current and future patient care. Utilize information resources (technology-based and non-technology based) to inform and support patient care decisions. Use appropriate clinical consultation to improve patient care. Use and improve time management skills to care for patients efficiently and effectively in the ambulatory arena. Interpersonal and Communication Skills Conduct all interviews with patients and their families in a compassionate, culturally effective, and patient-centered manner. Use specific communication skills to communicate effectively with patients who are elderly have chronic or recurrent illnesses are angry frustrated, or have poor cognitive functioning. Demonstrate effective negotiation and meditation skills with the following patients: • Narcotic seeking patients

• Angry or frustrated patients • Angry or frustrated families of patients • Patients who disagree with recommendations for medical care Demonstrate effective communication skills with patients and their families surrounding end-of-life decisions Demonstrate compassionate, effective communication, and counseling of patients with addictive behaviors (tobacco, alcohol, recreational and prescription drug abuse), or who are victims of domestic violence, elder abuse, or poverty. Perform effective telephone management of patients between visits, including (but not limited to): • Explaining and acting upon results of studies/labs • Triaging complaints from patients at home • Managing chronic illnesses (e.g. diabetes, depression, CHF) Communicate effectively with all consultants providing mutual care for patients. Complete all dictations, letters, and consultation requests in a timely manner. Professionalism Seek methods to enhance effective communication and understanding with patients of different cultural and ethnic backgrounds, socioeconomic status, and educational level. Avoid judgmental behavior in patients with chronic pain syndromes and demonstrate effective skills to plan appropriate pain treatment regimens in collaboration with the patient. Demonstrate ethical patient care, weighing all decisions with patient values. Provide timely care in the outpatient setting, making efforts to avoid excessive patient wait times, while also allowing for patients who may be reasonably late. Work as a member of a team of health care providers, helping to offset excessive clinical volume as it affects other practitioners. Provide meaningful feedback to colleagues and students regarding performance and behavior. Complete and review all dictations in a timely manner. Systems Based Practice Understand and utilize community resources and programs for referral of patients with the following conditions: • Alcohol abuse • Recreational drug abuse • Prescription drug abuse • Smoking • Depression and Anxiety • Psychosis • Geriatric issues • Domestic Violence • Child or Elder Abuse Interact with and utilize social workers, nurses, medical assistants, billing coordinators, and referral coordinators to provide effective comprehensive patient care.

Recognize deficits in logistical aspects of the health care delivery system and participate in systems-based improvement initiatives. Understand, discuss and actively consider the following systems-based issues when they are relevant to individual patient care: • Billing and Documentation • Health Economics – Medicare, Medicaid, insurance issues • Managed Care • Medical Ethics • Medicolegal issues • Quality Assurance

Teaching Methods Learning during these rotations is primarily patient-based. The amount of time to spend reading about a particular patient’s disorder is far more limited in the clinic setting than when on an inpatient service. Therefore, the acquisition of new knowledge, attitudes and skills takes place while patient care occurs, predominantly through the resident-attending staffing encounter. It is expected that all patients are staffed by general medicine attendings. As a resident’s experience in general medicine grows, it is expected that decisions will be increasingly made by the resident, with faculty reviewing and modifying as necessary. Important elements of the staffing encounter are as follows: • Important aspects of the patient’s history and presented by the resident and jointly reviewed. • Pertinent elements of the physical examination are presented by the resident and reviewed by the attending. It is desirable that important findings are reviewed at the bedside by both parties. • Medical decision-making is a joint venture, with an increasing role by the resident as experience grows. Explicit statements about the rationale behind decisions are crucial to promote learning and to promote critical thinking among the residents. • Medical decision are augmented by the search for answers to clinical questions during patient care, or soon afterwards. Information resources (both paper-based, Internet-based, handheld) are easily available in all clinic settings and should be extensively used to inform decisions. In addition, formal and informal learning about ambulatory care topics will occur in other settings: • Reading about patient-specific clinical questions after and between clinics • Bi-monthly journal clubs covering primary care topics • primary care clinical conference • Ambulatory morning report • Monthly ambulatory care conference in continuity clinic (www.hopkinsile.org) • Afternoon seminars during block rotations

Outpatient sites: Camden Three Cooper Plaza Camden, New Jersey 08103 Preceptors: Anna Headly, M.D., Pamela Turnbo, M.D., Pamela Zee, M.D. Washington Township Bunker Hill Plaza, 1 Plaza Drive Chapel Heights/Hurffville-Crosskeys Road Sewell, New Jersey 08080 Preceptors: Anita Bulei, M.D., Joseph Libby, M.D. Voorhees 900 Centennial Boulevard, Suite M Voorhees, New Jersey 08043 Preceptors: Nancy Beggs, M.D., Mark Angelo, M.D., Patrick Abuiso, M.D. Pennsville 390 North Broadway Concorde Building, Suite 100 Pennsville, New Jersey 08070 Preceptors: Kevin Ellis, M.D., Thomas Howard, M.D., Allen Auerbach, D.O., Daniel Jordan, M.D. Magnolia 446 North White Horse Pike Magnolia, New Jersey 08049 Preceptors: Arnaud Bastien, M.D., Anton Kemps, M.D. Gloucester City 14 South Broadway Gloucester City, New Jersey 08030 Preceptors: Daniel Hyman, D.O., Charles Brennan, M.D. Cherry Hill 1210 Brace Road, Suite 102 Cherry Hill, New Jersey 08034 Preceptors: Gerald Abelow, M.D., John Kirby, M.D., Frank Ferri, D.O. Cherry Hill 1103 North Kings Highway, Suite 203 Cherry Hill, New Jersey 08034 Preceptors: Diane Barton, M.D., Anthony Sherman, M.D. Duration: A minimum of 1 half-day session/week A one-month ambulatory rotation during the 3rd year of training

Trainees must attend a minimum of 108 weekly continuity clinics during a 36 month training period. Curriculum: As a general rule, interns, average over 1 years, must see no less than 3 patients per session and no more than 5. PGY-2 must see no less than 4 and no more than 6 patients per session PGY-3 must see no less than 4 and no more than 7 patients per session Residents are required to keep a patient logbook throughout their training. Residents are also required to participate on the John Hopkins Ambulatory Care Online Curriculum, a web based educational resource that focuses on the major topics of ambulatory medicine. House staffs participate in instructional modules and are evaluated thereafter, with a complete report available to the program directors. House staff are required to fulfill one modules/ month Curriculum: for year 2004--2005 Adolescent Medicine: Topics for the General Internist Anemia: Diagnosis and evaluation Basic Dermatology and dermatitis for the Internist Bioterrorism Cancer Screening Dementia: Diagnosis and Management Depression: Diagnosis and Management Diabetes: Diagnosis and Management Emerging Screening Techonologies (2003-2004) GERD Headaches: Diagnosis and Management Hip and Knee Pain Hormone Replacement Hypertension: Diagnosis and Management Immunizations Low Back Pain: Diagnosis and Management Obesity and Overweight: Diagnosis and Management Office Gynecology for Internists Osteoporosis: Diagnosis and Management Outpatient Palliative Care Preoperative Evaluation Preventive Cardiology Professionalism Respiratory Tract Infections Evaluation: All residents are evaluated on the following core competencies periodically through attending evaluation. For continuity clinic, evaluation will occur twice per year. For block rotations, evaluation will occur monthly. Specific feedback should be delivered in a timely manner to allow residents to plan a self-improvement strategy.

1) Summary Evaluation every 6 months by outpatient preceptor 2) Evaluation at the end of 1-month ambulatory rotation by preceptor for third year residents 3) Mini-Cex form to be filled out every 3 months by preceptor and at end of one-month ambulatory rotation. 4) John Hopkins Online Ambulatory Care curriculum web based multiplechoice question for two assigned module every month. Program director have access to the results of all the web based curriculum evaluation methods. 5) 360 evaluation from the front desk of the office manager

. Resources Schedule Monday AM PM Varies by rotation

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