
of complex medical patients in an outpatient setting referred
from the Emergency Department or community care providers.
The A-CTU provides a different learning experience than a
traditional outpatient clinic for several reasons. To begin, this
clinic provides an opportunity for PGY3 learners to practice
higher-level skills required for an academic clinician working in
an outpatient practice. This includes supervising and reviewing
cases with multiple learners or physician extenders (physician
assistant or nurse practitioner) in the outpatient setting, triaging
referrals, and following up on critical results. Similar to the
traditional CTU, there is also a full allied health team present
in the A-CTU, including a pharmacist, occupational therapist,
and social worker. Residents learn how to collaborate with
these providers in the ambulatory setting. There is a formal
academic curriculum on the A-CTU. This includes a dedicated
physical examination curriculum guided by PGY3 residents for
the PGY1 residents and an afternoon report where interesting
or challenging outpatient cases are discussed with all levels of
learners. Furthermore, the A-CTU provides an opportunity to
seek consultation from sub-specialty services sharing the clinic
space. The Boris clinic often has General Internal Medicine,
Diabetes, Dermatology, Thrombosis, Hematology, Obstetrical
Medicine, Rheumatology, Respirology and Infectious Disease
clinics running concurrently. If a sub-specialty opinion would
be of value, the PGY1 resident can seek formal or informal
consultation from the relevant specialist. This is both encouraged
and welcomed within the culture of the A-CTU. Also, there is
access to an ultrasound machine and procedural equipment.
Thus, similar to the CTU, learners can gain procedural or point-
of-care ultrasound skills while on the A-CTU.
Preceptor-Based Senior Medical Resident Role
In addition to functioning as a senior resident on a traditional
CTU, our senior residents complete a preceptor based inpatient
internal medicine rotation where they work under the direct
supervision of an attending physician. The one-on-one teaching
experience between faculty and senior learner sets the stage for
meeting targeted learning objectives and graded responsibility. We
anticipate that many of our graduates will work in community-
based hospital environments without formal CTUs, thus felt it
was important to develop the skills to function as an independent
practitioner. In the preceptor-based rotation, the senior resident
is responsible for independently managing inpatients. The
resident will complete all necessary clinical procedures. They
are responsible for reviewing the initial consultation with the
overnight admitting team, as well as bedside management
and discharge planning. This rotation also allows for direct
observation and feedback for the learner, which is important
in our current CBD curriculum.
Consultation and Follow-Up Medical Team
The traditional CTU usually manages patients admitted overnight
by
the on-call team. We have found it to be a challenge to both
education and clinical service for these teams to see new consults
during the day. For this reason, a new hybrid daytime consultation
team was developed. This team consists of a senior resident
and
1–2 junior learners who admit new consultations from the
Emergency department during daytime hours. The majority of
patients admitted by this team are followed until discharge. To
ensure this team can provide excellent clinical care and meet its
educational mandate, the number of patients is capped at 15–17.
Additional patients are then transferred to other clinical teams.
By
admitting new patients in the daytime, the learners have the
opportunity to receive direct observation and feedback from
the
supervising attending. In addition to commenting on the
history
and physical examination skills, the resident will have the
opportunity to receive feedback on management and resource
utilization at the time of admission. This is often missed when
reviewing a large number of patients in the morning. Also, by
having active inpatients and admitting new patients, the learner
will
learn how to manage time and priorities during the day.
In
addition to improved education, this rotation has helped to ensure
that daytime consults are seen promptly.
Social Medicine Rotation
We have identified that the CTU environment does not
consistently provide trainees with the skills or knowledge
required to provide optimal care to vulnerable patients, many
of
which have unique healthcare needs both in hospital and the
community. This rotation was designed to provide a breadth
of
community and hospital-based learning experiences to
familiarize trainees with at-risk populations (for example
newcomers, inner-city populations and patients with chronic
illness and disability, mental health or substance abuse
disorder
), the social determinants of
health and available
resources.
Our medical learners are provided an elective opportunity (for
either two or four weeks) to be part of this clinical service.
During
this rotation, the learner is paired with a faculty supervisor
who
provides an individualized orientation regarding expectations
and an
introduction to social medicine. The same supervisor
will debrief
with the learner weekly, review personal reflections
and compile
their assessments. The rotation is comprised of a combination of
core and elective half-day experiences, which include (but are not
limited to): inpatient addictions medicine, home visits with an
internist caring for vulnerable populations,
outpatient addictions
medicine clinics, shelter health clinic,
tuberculosis clinic, refugee
health clinic, aboriginal health clinic,
pre-exposure prophylaxis
clinic, needle exchange programs,
shadowing addictions workers
or social workers.
10 V o l u m e 1 5 , I s s u e 1 , 2 0 2 0 C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e
Teaching and Learning
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