Keywords

Introduction

The ambulatory clinic is a critical learning venue for internal medicine residents to master the skills necessary to provide outstanding care in an outpatient environment. The resident clinic director oversees the ambulatory clinic and focuses on the clinical and educational missions for residents, patients, and faculty. It is the goal of the ambulatory clinic director to foster resident training that ensures residents gain the knowledge and skills necessary to practice independently in an outpatient setting and within an inter-professional team. This includes making sure residents become exposed to and skilled in varied areas of medicine, including chronic disease management, preventative care, mental healthcare, substance abuse, acute care, and population management. 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 for Quality Assurance (NCQA) standards that apply to primary care settings [1]. The clinic director works closely with faculty preceptors and clinic staff to create a positive experience for residents that balances education and service. In addition, she/he is a liaison to the residency program director and associated staff [2].

Learning Objectives

  1. 1.

    Understand the position requirements for a residency clinic director.

  2. 2.

    Recognize accountabilities for the residency clinic director, including clinical, academic, quality, and administrative missions.

Outline

  • Position Requirements

  • Accountabilities

    • Clinical Mission

    • Academic Mission

    • Quality Mission

    • Administrative Mission

Position Requirements

The resident clinic director may be a role served by individuals in different positions across institutions, but all should be certified by the American Board of Internal Medicine [2]. For example, he/she might be a core faculty member, an associate program director or the medical director of a clinic. Because of the somewhat nebulous definition of the role, the salary support often varies from institution to institution as well as the protected time allotted.

It is good practice to ensure that the resident clinic director has significant experience in resident precepting in an outpatient setting, previous participation in resident educational conferences, and strong leadership skills. In addition, it is important that this individual have excellent communication and problem-solving skills to handle challenges that invariably come up. Experience in curriculum development, resident assessment, quality improvement, panel management, and primary care research are also desirable traits. However, recruiting other faculty members to aid in tasks is often necessary, making strong organizational skills essential. The ability to handle residents, staff, and patient complaints pertinent to the resident clinic in a productive and constructive approach is another critical attribute. Continuity clinic staff should enjoy working in a resident clinic environment and understand the need to balance the educational and patient care missions. Team-based care should be modeled and taught with a patient-centered approach [3].

From an administrative standpoint, he/she will frequently meet with program administration to ensure that patient care and educational goals are aligned and that the Accreditation Council for Graduate Medical Education (ACGME) requirements are met [4]. This will often involve active engagement in the residency infrastructure, including potential participation in Program Evaluation and/or the Clinical Competency Committee (CCC). He/she will also collaborate with faculty and the section chief to make sure the expected relative value units (RVUs) and/or educational value units (EVUs) are achieved (further discussed in chapter “Outpatient Billing and Coding”).

Principle Accountabilities

Clinical Mission

During the academic cycle, the clinic director or delegate starts the year by orienting the new interns and residents to the clinic. This often includes arranging for additional electronic health record training that may not be part of the overall graduate medical education (GME) orientation. Residents meet the staff and become familiar with both the structure and the day-to-day operations of the clinic. Some programs may choose to have ambulatory intern “boot camps” to orient residents to the clinic [5]. 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. Graduating resident panels are often assigned to the new PGY-1 or PGY-2 panels during June/July of the academic year [6]. This ambulatory handoff process is a necessary function of the clinic to ensure that patients’ continuity of care is maintained through this time of transition, a key component of high-quality care [7].

As the academic year progresses, the clinic director may serve as the point person when clinic protocols develop or change to make sure 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 point person 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 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 residents work with faculty who are dedicated to the educational and clinical mission of the clinic [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 outpatient conference series, which require curriculum development, faculty recruitment, and faculty development to ensure a robust curriculum. This may include didactic experiences, small group workshops, resident-led presentations, self-study with electronic resources, quality improvement activities (discussed in chapter “Ambulatory Curriculum Design and Delivery for Internal Medicine Residents”), and panel management (discussed in chapter “Maximizing Continuity in Continuity Clinic”). The academic offerings of the clinic must undergo consistent assessment, based on ongoing evaluation and feedback by the learners.

For residency 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. 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. Recent studies have shown that the likelihood of entering a general internal medicine career may be linked with satisfactory experiences in the ambulatory continuity clinic [8].

Quality Mission

The clinic director must follow NCQA guidelines to meet accreditation requirements for the PCMH and familiarize residents with these principles. In addition, features of ongoing primary care transformation which occurs in the patient-centered medical home 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 the medical homes. Competencies and entrustable professional activities (EPAs) are tied to many of the clinical tasks, which can be observed and integrated into feedback [9].

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 (see chapter “Maximizing Continuity in Continuity Clinic”), patient volume, no show rate, cycle time, 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 ever-changing landscape of medicine.

Administrative Mission

In addition to the clinical, academic, and quality missions, it is important to recognize the administrative expectations of the position. A basic working knowledge of accepted principles of accounting and care business management skills can be helpful. For instance, the residency clinic director must negotiate with clinic administration to assure the clinic has a sufficient number of exam rooms, equipment, and supplies. They must also advocate for acceptable clinic staffing, including nursing and assistants along with adequate access to social work, case management, and pharmacy. He/she must effectively interface with the program director to assure timely clinic schedules and to minimize disruptions to the continuity experience. As noted above, it is also critical to negotiate appropriate support and protected administrative time for the clinic director position and to assure that productivity expectations are achievable. They must provide support to the other preceptors, including assistance in delivering feedback and remediation as well as offering mentoring for junior faculty.

Conclusion

For a successful clinic experience, the medical resident clinic director should be an individual with a mastery of patient clinical care, residency education, and office practice management [2]. With approximately one-third of residency time spent in the ambulatory setting, a positive clinical and educational experience is a key component of residency training and can also promote interest in primary care.