Clinical Triennium - PGY 2/3 Long Block
The Long Block begins in the 17th month of residency for a total of 12 consecutive months. We chose this time because we felt it was important for you to consolidate your inpatient skills as team leaders and care givers prior to the Long Block.
In developing our model, we felt that one year of true continuity would be better for care and education than three years of sporadic interactions. The results have been extremely positive. Our work was recently cited in a New England Journal of Medicine article entitled, Experiments in Continuity — Rethinking Residency Training in Ambulatory Care.
Other recognition we have received includes:
During the Long Block, you will transition from inpatient-based rotations to an expanded outpatient experience and you will help take care of approximately 150 patients as part of your primary care panel.
You will see these patients in the ambulatory practice three half-days per week, but are required to be present in the practice or check the electronic medical record (to answer messages, etc.) at least once a day. In short, you will act like practicing physicians.
We have designed scheduling systems to prioritize continuity of care. For example, your daily schedule of eight appointments has two slots protected for acute patients, and we make every effort to match your patients with you when they need care.
When not seeing patients in the practice, you will rotate on inpatient or ambulatory electives as well as research experiences with minimal overnight call (two to four weeks of inpatient night-float).
During the 12 months of Long Block you can take up to three different electives in any one field of medicine, and up to three months dedicated time for research. You also receive protected time to learn during the Advanced Ambulatory Practice and Board Review sessions.
Our ambulatory practice is an urban safety-net practice attached to the main university Medical Center. Within the practice, you will work with a multitude of providers including nurses, medical assistants, licensed social workers, a depression care manager, a diabetes educator, pharmacists, sports medicine physicians, general surgeons, women's health specialists, and numerous others.The facility also provides access to a laboratory and pharmacy.
Most of the patient we care for are insured by Medicare, Medicaid, or are self-pay and otherwise have limited access to medical services. You will receive special training on taking care of vulnerable populations.
You will also develop a concept for population health management during this time. On a monthly basis, a dedicated information technologist extracts data from the electronic medical record on each of the practice's 8000 patients. The data helps track clinical performance with regards to health maintenance and best practice metrics, such as immunizations, blood pressure and diabetes control. With this registry you will be able to plan for each of your clinic sessions and quickly access patient data to guide your goals for the day. You will then huddle with your nurse prior to each clinic session to direct a joint effort toward achieving those goals.
You will participate in weekly team meetings with the clinical staff, chief resident, and program director to identify process improvement and patient access issues.
You will receive training in Lean methodology and the Model for Improvement to help address issues that arise in clinic. For example, one of the biggest challenges the practice faces is the rate of uncontrolled diabetes; approximately 25% of the clinic’s 2000 patients with diabetes have HgA1c > 9%. This past year, the focus of our quality improvement and population health efforts have been geared at reducing this rate. Residents identified several areas for improvement in the delivery of care for these patients, including medication adherence and access to specialized care providers including diabetes educators and endocrinologists. A subset of residents have taken further action to develop specific approaches for managing diabetes. They have worked to develop a patient survey regarding medication management and are developing a specialized, interdisciplinary diabetes clinic to improve patient access to specialists. Utilizing updated patient registries, the residents are readily able to identify diabetic patients with poor control and perform chart reviews with regards to their utilization of healthcare resources, refill rates, visits to specialists, etc.
There are other avenues that are available to the residents at the University of Cincinnati to further engage in population health. The Community Health and Advocacy program is a learning pathway available for residents with a particular interest in the management of vulnerable populations. Residents involved in this pathway are engaged over the entire course of residency, and complete the “Caring with Compassion” curriculum from the University of Michigan, with modules that address social determinants of health, insurance and delivery systems, and team-based care. There is also a dedicated elective, the Initiative on Poverty, Justice and Health, that residents may opt to take during their Long Block experience that is geared at recognizing the social determinants of health specifically for our patients in Cincinnati. Residents spend the majority of time away from clinic and the hospital, venturing into the community to learn about homeless shelters, food banks, and other community-based resources in the greater Cincinnati area.