Ambulatory Education

Jennifer Lukela, MD
Associate Program Director

"Provide all our residents with the knowledge and skills necessary to practice as excellent outpatient general internists in academic or community practice settings." - Jennifer Lukela, MD

The majority of medical care occurs in the ambulatory setting. As a result, internists must be comfortable evaluating and managing both acute complaints and chronic conditions outside the hospital.

A goal of the University of Michigan Internal Medicine Residency Program is that all our graduates will be comfortable with the practice of general internal medicine in the outpatient setting. While the majority of our residents will elect to pursue further training after residency in subspecialty practice, we believe these core skills in outpatient general medicine will serve them well in aspects of their future practice and in their overall development as internists. 

                

Outpatient Clinical Experiences

Our residents gain clinical experience in the practice of Internal Medicine in the outpatient setting through three main rotations or longitudinal experiences:

  • Continuity Clinics
  • Ambulatory Block Rotations
  • Outpatient Clinical Electives

Continuity Clinics 

Residents will be assigned to a continuity clinic in one of three locations: 

  1. Taubman General Medicine Clinic (located in an outpatient building adjacent to University Hospital)
  2. General Medicine Clinic at the Ann Arbor VA Hospital
  3. One of four University of Michigan Health System clinics located in our local community:
    • Briarwood Medical Group
    • Brighton Health Center
    • Canton Health Center
    • East Ann Arbor Health Center

A primary goal of our continuity clinic experience is for residents to maintain longitudinal relationships with patients throughout their training. Since all of our continuity clinic sites serve as Patient Centered Medical Homes, this is an opportunity for our residents to gain experience in panel management and general quality improvement (QI) principles in population health.

On average, residents are scheduled for one half day of continuity clinic per week with additional time in their assigned clinic during their ambulatory block rotations.

Curriculum

  • All interns participate in an “immersion week” in clinic early in their training to improve comfort in their clinic setting.
  • Emphasis on experiential learning from patient encounters with guidance from expert clinician-educator and research-based general internal medicine faculty.
  • Direct observation of clinical and communication skills
  • Monthly outpatient teaching sessions with your continuity clinic faculty:
    • Web-based knowledge content modules
    • Case vignette presentations
    • Evidence-based literature reviews
    • Quality Improvement/Panel Management

Ambulatory Block Rotation

The Ambulatory Block Rotation combines general and subspecialty outpatient experiences supplemented with didactic sessions and self-directed learning focused on broadening medical knowledge pertinent to the outpatient clinical setting. Upon successful completion of these rotations, residents will be able to diagnose and manage a wide range of acute and chronic internal medicine disease states. Residents will understand the logistics of care in the ambulatory setting and have the ability to work in a variety of practice environments. They will also be familiar with the care of a variety of patient populations in the ambulatory setting.

This rotation is mandatory for residents at all house officer levels. All interns will complete at least one ambulatory block rotation (primary care track residents may have the opportunity for two rotations). Senior residents will complete one-two ambulatory block rotations per year with additional outpatient training opportunities for residents participating in the primary care track.

In the House Officer (HO) 1 year, the Ambulatory Block Rotation will include an emphasis on primary care medicine in the community setting along with exposure to underserved and high-risk populations. There will also be ample time in continuity clinic to allow interns to begin to build their patient panel and develop increased confidence in their continuity clinic setting.

In the HO2 and HO3 years, the Ambulatory Block Rotations will focus more on subspecialty clinical experiences highly relevant to primary care practice (ie, ophthalmology, gynecology, ENT)

Teaching to Teach

The Teaching to Teach (T3) curriculum is a mandatory experience, delivered over a four-week period within the ambulatory care rotation. During that time, Dr. Lukela and her co-instructors introduce residents to such subjects as clinical reasoning, the process of identifying cognitive errors in decision making, and the integration of evidence-based medicine into teaching.

“We then give senior residents pedagogical tools such as ‘advance organizers’ — a means of illustrating the relationship between what students are about to learn and what they already know — to teach younger residents and med students. We also require residents to build and present their own teaching scripts, which are later made available for others to access.” - Jennifer Lukela, MD

The other components of the T3 curriculum include developing presentation and feedback skills and validated tools for quick clinical teaching like the One Minute Preceptor.

Learn From the Best

The next step in the process is showing residents how to turn theory into practice. The observation of “master clinician educators” is part of our new Medical Education Elective which is a two-week elective for senior residents. During this rotation they observe teaching rounds, lead education conferences for medical students and interns, and teach medical students physical exam and history taking skills. The key here is to “watch the teaching, not the medicine,” and learn from the best.