The Tulane Internal Medicine Residency Program places a strong emphasis on outpatient medicine for all residents, whether they be categorical or primary care. All residents will complete more than 200 clinic sessions over a three-year residency, far exceeding the 130 required by the ACGME, and have over 25 three-hour "Ambulatory School" conferences devoted to topics in ambulatory medicine.
For these reasons, the primary care track does not focus on providing additional clinic time or additional time to learn outpatient medical knowledge. Instead, it focuses on providing residents with additional skills in panel management, practice management and community engagement. In short, the Tulane Internal Medicine Primary Care Track is designed to create Primary Care Leaders, developing the leadership, management and communication skills requisite for running a patient-centered medical home upon their graduation. Whether its academic or community-based primary care clinics, it's no wonder that Tulane graduates go on to leadership positions in primary care.
How the Track Works
As opposed to other residency programs where primary care residents are in parallel to the remainder of the residency program, the Tulane Primary Care Track residents are integrally involved with all residents in the program. The “4+1” system is the key…
Under the “4+1” system, the residency program is divided into five firms. Each week, one of the five firms devotes their time to primary care continuity clinics (the “+1 weeks”); the other four firms staff the standard inpatient ward, ICU, ER and elective rotations. During these "+1" continuity clinic weeks (ten clinic weeks per year), all residents have protected time to devote to the care of their primary care patients without the distraction of ward or elective duties. Importantly, this system enables patients to schedule clinic appointments with their primary care provider anytime within the clinic weeks, without the guess-work that is a feature of the standard system where resident clinics are only on a half day per week, and frequently cancelled or moved due to post-call, on-call or ICU/ER duties.
But what happens in the four weeks that intervene between a firm’s primary care “+1” week? The answer is the Tulane Primary Care Residents nested within each firm. Each firm has three residents who, as a product of their interest in primary care as a career, serve as the Firm’s Primary Care Directors. The firm's primary care cohort teams up to provide leadership and oversight of their firm's primary care panel in the four-week inter-sessions between the firms "+1" continuity clinic weeks. This rotation is affectionately known as "STARDUST!".
The Clinical Curriculum
All interns in the primary care track do the same rotations whether they belong to the primary care track or not. We believe this is important, since it establishes a strong foundation in general internal medicine, and enables the primary care resident to appreciate the intracies central to understanding successful transitions-of-care from the inpatient to the outpatient environment.
STARDUST! The STARDUST! Rotation is devoted to managing the firm's continuity clinic panel in the four-week intersessions between the firm's +1 weeks. The senior (PGY-2 and PGY-3) primary care residents nested within each firm team up to cover the 10 STARDUST! Rotations each year. Each primary care resident obtainss the leadership and communication skills of managing a patient-centered medical home by managing their firm's primary care panel for five three to four of the ten STARDUST blocks each year. The other six to seven blocks are devoted to fulfilling the standard inpatient and elective training requirements. Compared to categorical residents, primary care residents have one less elective month in their second and third year, and one less CCU/ICU/Moondog rotation over the final two years.
One key feature of the primary care track is that residents on the track have their continuity medicine clinics at the Tulane University Community Health Centers starting in their intern year. These clinics are NCQA-certified level 3 patient-centered medical homes, and serve as a home base for many of the activities specific to the primary care track.
Other distinguishing features of the primary care track include the primary care journal clubs, speakers who come address the primary care track, and primary care skills workshops. Through these activities the primary care track comprises a home within their home in the residency program, allowing residents interested in primary care to have additional opportunities to gather around their future career path. By the completion of their residency, primary care track residents also present a research project at a local, regional or national meeting (all expenses sponsored by the program).
Primary care residents also devote one month to the "Fisherman's Platter" elective (providing an assortment of clinics to augment outpatient procedures such as skin biopsies, joint injections, IUD placements, etc.) and the "ZIGGY!" month. During this rotation, residents manage disease registries and perform quality improvement research; they precept at the free, medical-student-run Fleur de Vie Clinic; they attend dermatology, PMR and adolescent medicine clinics to acquire key procedural skills; they work at the Rebuild Clinic to gain skills in working with the homeless population; and they have additional flexible time which they can use to devote to additional research or clinical experiences or other activities of their choice. The combination of the "ZIGGY and STARDUST" months, in addition to the additional curriculum components noted above, ensure that the Tulane Primary Care resident graduates with exceptional preparation to assume the leader of a patient-centered medical home.
Click on the image for a full view of the Primary Care Sample Curriculum
Developing Leadership and Collaborative Skills
But it is not mere clinical care that defines the track. Residents serve at the firm leaders, interacting with firm members and making all decisions regarding ambulatory-based care for their firm. Further, the residents acquire valuable skills in working with the clinic leadership and staff (overseeing schedule templates, participating in the clinics’ policy/procedure discussions) and working with non-physician staff (social workers, pharmacists, nurses, nurse practioners) in coordinating all continuity care. In doing so, residents gain valuable leadership and management experience, fully preparing them to lead their own primary care enterprise as a patient-centered medical home upon their graduation.
Developing An Academic Career in Primary Care
Primary care residents work closely with Dr. Eboni Price, Dr. Karen Desalvo, Dr. Lydia Bazzano, and the Primary Care Director, Dr. Philip Skelding to receive the mentorship required to advance an academic career in primary care. As the Track provides for exceptional protected time, residents have the time and mentorship to participate in outcomes-based research in primary care. In this way, the Tulane Primary Care Track is unique… residents change the face of primary care by their scholarly pursuits, further preparing them to assume a leadership role upon their graduation.
The Primary Care Track Residents also gain valuable teaching experience as a part of their training. During the “+1” primary care continuity clinic weeks, a half-day is devoted to multidisciplinary curricular time in which the firm’s resident, nurse, nurse practioner, social worker, and pharmacist trainees all engage in an ambulatory-based curriculum. The curriculum provides elements of team-based simulation, using the Tulane University Simulation Center, in addition to reflective-exercises in which patient care events over the previous month are reviewed with a focus on performance improvement.
Mastering Transitions of Care
Meaningful training and preparation for a career as a primary care team leader requires that the trainee master transitions of care, and learns to facilitate care with other subspecialists. In the Tulane system, the primary care residents manage the transitions of care for all of their firm’s patients (inpatient to outpatient, and outpatient to inpatient), as well as working with colleagues in their firm who have subspecialty clinics, to facilitate subspecialty care. By definition, when a Primary Care Resident is working as the firm’s Primary Care Director in the four-week intersessions, other members of his or her firm will be staffing the inpatient ward services. When a patient is scheduled to be discharged from the hospital, his or her firm colleague will be calling the Primary Care Resident to facilitate the transition to ambulatory-based care. Learning how to manage these transitions is important for all members of the firm, but the augmented experience the Primary Care Resident receives as the team leader in management of these transitions is invaluable to his or her subsequent career as Primary Care Leader.
The Uniqueness of the Tulane Primary Care Track
No where else will you receive the leadership, management, communication, and research skills requisite for a successful career in Primary Care. If assuming a leadership position in primary care is your goal, look no more… Tulane is the home for you!
While anyone can enter the Primary Care Track at any time, the Program has made a commitment to ensuring that each firm has a minimum number of residents devoted to Primary Care by devoting three positions in each year’s match to those interested in Primary Care. Via the NRMP system, you will find a separate “match code” for the Tulane Primary Care Track. Applicants can apply to both the Categorical (3073140C0) and Primary Care (3073140C1) tracks, and can list both on their match list.
Dr. Philip Skelding is the director of the primary care track and the Associate Program Director overseeing all ambulatory training in the residency program. Please contact him with any questions you have regarding the primary care track – pskeldin@tulane.edu
