Keywords

Introduction

The clinic director plays an instrumental role in a successful clinic experience for trainees, faculty, staff, and patients. This chapter provides an overview of the general expectations and qualifications of an academic medical clinic director. The responsibilities of a clinic director will be reviewed including the clinical, academic, quality improvement, and administrative missions. Lastly, the relationship between the clinic director and health care administration will be discussed as this can present both challenges and opportunities for the clinic director as well as the overall clinical environment.

Outline

  • Background

  • Overview of clinic director role

    • General expectations

    • Qualifications

  • Principal responsibilities

    • Clinical mission (clinical operations)

    • Academic mission (residency program, resident/medical student education)

    • Quality mission

    • Administrative mission

  • Working with health care administration

  • Conclusion

Background

The ambulatory clinic is a critical learning venue for internal medicine residents to master the skills necessary to provide outstanding care in the outpatient clinic. The resident clinic director plays an important role, with responsibility for oversight of the clinical and educational missions for residents while assuring a supportive learning environment. In addition, the clinic director must work closely with faculty and staff, helping navigate the inherent challenges of care delivery in a teaching clinic. Every ambulatory clinic director should strive to foster a resident training experience that will help residents gain the knowledge and skills necessary to practice independently in an outpatient setting and within an inter-professional team. This includes making sure that residents have sufficiently broad exposure to allow for skill development in varied areas of medicine, including acute care, chronic disease management, preventative care, mental health care, substance use disorder care, population management, and practice improvement. The clinic director must keep up with the changing and challenging landscape of medicine and be a champion of quality improvement and patient safety. This typically involves understanding the patient-centered medical home (PCMH) and National Committee of Quality Assurance (NCQA) standards that apply to primary care settings [1]. The clinic director works closely with the entire clinic staff to create a positive experience for residents that balances the education and service needs [2]. He/she serves as a liaison to the residency program director and the residency administrative team [3].

Overview of the Clinic Director Role

General Expectations

In addition to the responsibility of overseeing the resident experience and caring for patients, the resident clinic director may have a variety of other roles. These may include serving as the clinic’s medical director, academic roles in residency leadership (such as associate program director, primary care program director, or core faculty), or other clinic and/or educational leadership positions. Because this role is not consistently defined, the salary support and protected time vary from institution to institution.

Qualifications

Clinic directors are expected to be certified by either the American Board of Internal Medicine (ABIM) or the American Osteopathic Board of Internal Medicine (AOBIM) [3]. It is good practice for the resident clinic director to have significant experience in outpatient resident precepting, previous participation in resident educational conferences, and strong leadership skills. In addition, it is important that this individual has excellent communication and problem-solving skills to handle daily issues. Experience in curricula development, resident assessment, quality improvement, panel management, and primary care research are also desirable traits. However, recruiting additional faculty members for these tasks is often necessary, making strong organizational skills essential [4]. The ability to engage with residents, staff, and patients effectively and productively in response to concerns about the resident clinic is another important attribute. Patient and resident physician continuity [5] (see Chap. 6) is important for the resident experience, and team-based care can enhance the resident experience [6].

From an administrative standpoint, he/she will frequently meet with program administration to ensure that patient care and educational goals are aligned and that all Accreditation Council for Graduate Medical Education (ACGME) requirements are being met (see Chap. 8) [7]. This will often involve active engagement in the residency infrastructure, including potential participation in Program Evaluation and Clinical Competency committees. He/she will also collaborate with faculty and the section chief to make sure that the expected work relative value units (wRVUs) and educational value units (EVUs) are well understood and appropriate (see Chap. 3).

Principal Responsibilities

Clinical Mission

During the academic year, the clinic director or delegate begins each year by orienting the new first-year residents to the clinic. Residents meet the staff and become familiar with both the structure and the day-to-day operations of the clinic. Although residents learn the majority of the clinic processes once they start seeing patients in the clinic, they clearly benefit from a well-organized orientation. This often includes arranging for additional electronic health record training that may not be part of the overall graduate medical education (GME) orientation and focuses on outpatient workflows (in-basket management, result notifications, ordering durable medical equipment, etc.). Some programs choose to have ambulatory intern “boot camps” to orient residents to the clinic [8]. Graduating resident panels are often assigned to the new intern or resident (PGY2) panels during the Spring, as this ambulatory handoff process is necessary to ensure that continuity of care for patients is maintained through this time of transition, a key component of high-quality care [8,9,10].

As the academic year progresses, the clinic director may serve as the point person when clinic protocols develop or change to make sure that all the residents can function well within an ever-evolving system. The clinic director often supervises resident activities that require an attending attestation such as anticoagulation encounters, prior authorization paperwork, and durable medical equipment forms. Given their role as a preceptor in the clinic, the director can also serve as a resource for residents, patients, faculty, and staff on feedback for issues that arise. It is common for resident clinic directors to oversee panel management activities and to provide oversight to result follow-up, chart documentation, consultations, and other tasks that may fall through the cracks when the resident is out of clinic. Some clinic directors may set up a resident coverage system to manage results and messages by residents in the clinic for residents who are out of the clinic. The clinic director should recruit and orient faculty preceptors to ensure that residents work with faculty who are dedicated to the educational and clinical mission of the clinic [3]. Throughout, team-based care should be modeled and taught with a patient-centered approach [2].

Academic Mission

Although patient care is often the focus of the resident continuity clinic experience, making sure that there is a strong educational program is critical. He/she often directs the resident conferences, which require curriculum development, faculty recruitment, and faculty development to ensure a robust curriculum [11]. This may include didactic experiences, small group workshops, resident-led presentations, self-study with electronic resources, quality improvement activities (discussed in Chap. 29), and panel management (discussed in Chaps. 25 and 27). The academic offerings of the clinic must undergo consistent assessment, based on input from evaluations and feedback by the learners.

For programs that offer a primary care track, the clinic director may coordinate the offerings of this track and should help support these residents with particular interest in primary care [12, 13]. Some institutions have a primary care program director who would then work with the clinic director to coordinate electives and academic conferences for the primary care residents.

Many residency programs have formal expectations for resident scholarship, and the clinic director may be requested to assist residents in performing research that is focused on the outpatient setting. As clinic directors may have limited experience or training in research mentorship, working with program leadership is critical to be confident that residents are receiving adequate support to successfully complete these projects.

In addition to the other academic roles, the clinic director is frequently involved in ensuring compliance with program requirements from the Accreditation Council for ACGME and ABIM. This requires close coordination with program leadership, including delivery of effective feedback and evaluation of residents as part of the assessment and support of their progress toward independent practice (see Chap. 10).

Quality Mission

The clinic director must be engaged in the quality improvement initiatives that are ongoing in the outpatient clinic and ensure that residents are aware and involved in this work. For practices that are designated as a PCMH, the clinic director should follow the NCQA guidelines to make sure that accreditation requirements are being met and familiarize residents with these credentialing standards. In addition, features of ongoing primary care transformation, a key aspect of the PCMH, must be openly discussed with residents, with the clinic director ensuring compliance within this system of care [1]. These efforts will guide curriculum development and learner assessment in medical homes. Competencies and entrustable professional activities (EPAs) are tied to many of the clinical tasks, which can be observed and integrated into feedback [14, 15].

With the increasing presence of Accountable Care Organizations (ACOs) and additional available metrics, the clinic director or faculty may review clinical data such as Healthcare Effectiveness Data and Information Set (HEDIS) indicators, patient volume, no-show rate, and patient satisfaction surveys. Additionally, it is important to participate in implementation plans to meet clinic goals based on these metrics, such as diabetes and hypertension management. It is essential for the clinic director to foster a safe environment for quality initiatives and be prepared to innovate and adjust clinic experiences for their trainees in the changing landscape of medicine.

The resident clinic director is also likely to be involved in efforts to review and improve the health of the population the clinic serves. This can include formal training in population health assessment and can blend in nicely with quality improvement projects.

Administrative Mission

In addition to the clinical, academic, and quality missions, it is important to recognize the administrative expectations of the position. For instance, the residency clinic director must negotiate with clinic administration to assure that the clinic has adequate workspace, exam rooms, equipment, and supplies. He/she must also advocate for acceptable clinic staffing, including nursing and assistants along with appropriate access to social work, case management, and pharmacy. He/she must effectively interface with the program director to assure timely clinic schedule availability and advocate for minimizing disruptions to the continuity experience. As noted above, it is also critical to negotiate adequate support for the clinic director position and to assure that productivity expectations are achievable and sustainable. Clinic directors must provide support to the other preceptors, including assistance in delivering feedback and remediation as well as offering mentoring for junior faculty.

Working with Health Care Administration

Given the broad roles and responsibilities of the clinic director, successful navigation of complex administrative structures is crucial. It is not unusual for the clinic director to have multiple reporting relationships, including program leadership, clinic leadership, and division/department leadership. The competing priorities within the leadership structure can create tension, as issues around clinical productivity and patient access can impact support for teaching time and other non-patient care activities. However, these challenges can also identify opportunities to improve clinical care and learning environment. Throughout these interactions, it is important for the clinic director to appreciate the complexities of health care delivery and medical education, all while making sure to advocate for themselves, their learners, and their patients. In dealing with challenges, they should make sure that all stakeholders understand the role of the teaching clinic and are able to fairly advocate for both patients and learners.

Conclusion

For a successful ambulatory clinic experience, the medical resident clinic director should be an individual with a mastery of patient care, residency education, and office practice management [3]. With approximately one-third of residency time spent in the outpatient setting, a positive clinical and educational experience is a key component of residency training. Clinic directors should be flexible and able to pivot when both small and large emergencies interface with the system such as the COVID-19 pandemic or natural disasters, as effective leadership is critically important. In addition, an excellent training environment can improve patient care and physician satisfaction and promote increased interest in primary care.