Ambulatory Care Selective

Goals  [top]

To provide students with advanced clinical experience in an area of their choosing;

1. To understand and explore some concepts of systems based practice and how they affect health care delivery.

Clinical Skills Objectives (70%) [top]

This component of the course will help you to improve your ambulatory patient care skills.

During the selective month, you should work to improve in the following areas:

In addition to developing your skills in the above areas, you are expected to identify two specific areas in which you will further develop your clinical skills, such as reading EKGs, identifying heart murmurs, or increasing your ability to provide care to dying patients. These areas should be defined after you evaluate your current strengths, weaknesses, and career goals.

Systems Based Practice Objectives (30%) [top]

Objective: By the end of this selective, the student should have researched one aspect of systems based practice within their clinical setting and presented their findings to their colleagues.

The ACGME (Accreditation Committee for Graduate Medicine Education) competencies for systems based practice states that:

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:
1.Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society; and, how these elements of the system affect their own practice.
2. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
3. Practice cost-effective health care and resource allocation that does not compromise quality of care.
4. Advocate for quality patient care and assist patients in dealing with system complexities.
5. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance. 

For the purposes of this selective, systems based practice is all the processes in the health care system that operate to provide care to individual patients and to populations from the appointment system, referral procedures to the governmental organization of health care. Systems based practice can be easy to overlook as a medical student as it focuses on aspects of health care to which you may have had little exposure. It addresses systems for patient care (e.g. type of medical coverage, health care resources, home resources, and cultural needs) that can seem peripheral on a busy inpatient service with extremely sick patients. But they are ultimately critical to successful patient care and to run a successful medical practice.

System Based Practice specifically includes:

1.      Patient advocacy

2.      Health care economics

3.      Teamwork

4.      Practice management

5.      Health care financing

6.      Health insurance.

7.      Health care systems

8.      Medico-legal issues

9.      Medical errors

10. Documentation

11. Co-ordination of health care

12. Cost/benefit considerations

13. History of the US health care system.

Project Ideas: To help you develop your SBP project for this selective, the following are a list of ideas for you to consider. 

1. Compare health care plans.

SBP Objective: To compare how different health care plans may effect the provision of health care and the cost to the patient. For example, compare the type of covered preventive health care for a patient with Medicare vs. private insurance.

2. Team care for chronic disease

SBP Objective: Describe the process of referral and consultation and the roles of other health care professional in the care of your patient, e.g. Diabetic patient with podiatrist, diabetic educator. May visit with the other professionals, examine communication channels, etc.

3. Compare health care systems

SBP Objective: Select a medical condition you have seen in your practice and research how another health care system (for example in another country) would treat this condition compared to the US health care system.

4. System improvement

SBP Objective: Describe how systems can effect patient care. Choose a system in the environment you are working that you think could be improved e.g. reporting of abnormal labs.

5. Impact of the health care system on accessibility to care

SBP Objective: Describe barriers to accessible health care experienced by the poor and resources available to overcome these barriers. Use patients you have seen to demonstrate the issues.

6. Develop your own project

SBP Objective: Define your own systems based practice objective and the project you would like to do to meet this objective.

Process [top]

One month prior to beginning your ACS, you must submit to your ACS Department Coordinator by mail or FAX a copy of your individual objectives for the clinical and SBP components of the course. You and your ACS Department Coordinator will review and refine these objectives before you go to your ACS site. You must also show them to your community preceptor so that he/she will be able to offer you advice and guidance on achieving them and to evaluate the degree to which you achieve them. You will not be able to begin your ACS rotation until these objectives have been reviewed and signed by your ACS Department Coordinator. At the completion of the rotation, there will be a debriefing session in Chapel Hill. Each student is required to prepare a 10 minute presentation about their systems based practice project.

Site Selection [top]

This course is organized by department. Students will be asked for a list of their preferred department and sites.

When considering sites for the ACS, you may want to think about the following:

Housing and Travel [top]

Please check http://www.med.unc.edu/ahec/students/travel.htm for the most current information on travel and housing.

Student/Resident Housing [top]

When AHEC housing is available, students are requested to use this lodging. Students choosing not to utilize available AHEC housing are responsible for securing and paying for their own lodging.

When AHEC housing is not available, UNC-Chapel Hill students are eligible to receive housing assistance @ $11.00 per night for the duration of their clinical rotation. To be eligible for lodging expenses, the housing should be at least 100 miles (round trip) from Chapel Hill or residence of the student. The AHEC Program Office will reimburse for students in Public Health, Allied Health, Dentistry, and Nursing. For medical, nurse practitioner, and pharmacy students completing approved rotations under the Office of Regional Primary Care Education (ORPCE), the AHEC in which the rotation occurs is responsible for providing the $11.00 per night lodging assistance. Questions regarding reimbursement for all other disciplines/students should be directed to the AHEC Finance Office prior to the rotation start date.

While most AHEC housing is conveniently located in the same city as the clinical site, some rural areas may require students to commute short distances between their housing and clinical sites. In these instances, the same mileage reimbursement of two round trips per week between housing and site may be applied.

Exceptions to any of the above rules will need approval from the AHEC Program Office at least two weeks prior to the rotation start date.

ACS COURSE ADMINISTRATORS AND COORDINATORS  [top]

Robert Gwyther, M.D.

Course Director 

966-2824 

Leanne Shook

Registration and Scheduling 

962-8338 

Anne Mounsey, M.D.

Linda Allred

Family Medicine 

966-2824

966-3106

Steve Kizer, M.D. 

Carol Carden

Medicine Department 

966-7776

966-7776

Allen Liles , M.D.

Robin Davis

Med-Peds Department 

966-6770

966-2504

Anna Marie Connolly, MD

OB/GYN Department 

966-4717

Julie Byerley , M.D.

Robin Davis

Pediatrics Department 

966-3172

966-2504

B. Anthony Lindsey, M.D.

Myra Daniel

Psychiatry Department 

966-4456

966-6997

Colin Thomas, Jr. M.D.

Stacey Owen

Surgery Department

966-4781

966-4781

Students selecting Family Medicine sites will receive a well rounded, broad-based experience. This is because you will be working with children, younger and older adults of both sexes, different socio-economic groups, and, at most sites, pregnant women. You will see acute and chronic conditions.

As you review the descriptions of our sites, you will notice two categories. The first category of practices are community health clinics and health departments in rural and urban settings. These practices are publicly-supported institutions dedicated to caring for the underserved. Physicians in these settings want to show students that high-quality medical care and a rewarding practice are available in public sector medicine. We strongly urge you to consider taking the selective in one of these sites.

The second are the offices of private practice physicians in solo, partnership or small group practice. Preceptors in these practices are committed to showing students the role of the community physician, who is not only responsive to the needs of the individual patient, but also aware of the family and social environment of that patient. One month prior to the start of your selective, contact Linda Allred, Department of Family Medicine, at (919) 966-3106 regarding your assignment.

Course Listing - Medicine  [top]

Internal Medicine offers a broad spectrum of ambulatory practice opportunities in urban and rural settings throughout North Carolina. Students will have the opportunity to choose general or multi-specialty Internal Medicine practices, or they may choose a health maintenance organization or public health center for their Ambulatory Care Selective site.

During the Ambulatory Care Selective, students will gain clinical experience in a new setting outside the academic medical center. In addition to the office setting, some sites offer the opportunity for caring for patients in their homes, nursing homes, or hospital settings.

At each Internal Medicine Ambulatory Care Selective site, students will work with one or two seasoned preceptors and refine their ambulatory care skills. In addition to clinical experience, students will also explore the community agencies near their practice setting that augment patient care.

Each Internal Medicine site has unique features, but the expectations and evaluation procedures outlined in the Ambulatory Care Selective overview apply to all Internal Medicine students. One month prior to the start of your selective, contact Carol Carden, Department of Internal Medicine, at (919) 966-7776 regarding your assignment.

Course Listing – Medicine/Pediatrics  [top]
Med-Peds has Ambulatory Care Selective sites in both private practices and community health centers, in rural communities and in urban settings. At the UNC Student Health Services site, students will work primarily with older adolescents and young to middle-age adults. At all of the other Med-Peds sites, students will work with patients of all ages--from newborn to geriatric. Each Med-Peds site has special features, but the expectations and evaluation procedures outlined in the Ambulatory Care Selective overview apply to all Med-Peds students.

One month prior to the start of your selective, contact Robin Davis, ACS Pediatric Administrative Coordinator at (919) 966-2504 regarding your assignment.

Course Listing – Obstetrics & Gynecology   [top]
Obstetrics and Gynecology offers a variety of options for the Ambulatory Care Selective. They all include exposure to both public and private patients and to multidisciplinary teams. The first three choices (Wake, Guilford, and MAHEC) concentrate the clinical experience around obstetrical care; the fourth choice (Scotland) is a traditional private practice and includes both gynecologic and obstetric care. The fifth choice (Planned Parenthood) does not include obstetrical care in the clinical focus. Students looking for an ambulatory care selective that includes interacting with a large number of Spanish speaking patients should choose the Wake site; students hoping to work with a nurse midwife should choose the MAHEC rotation.

Course Listing – Pediatrics  [top]

Pediatrics offers Ambulatory Care Selective sites in solo and group private practices and health maintenance organizations. There are pediatric ACS sites in rural communities and in urban settings in all regions of North Carolina. Depending on the site, ACS pediatric students will work with patients from all socio-economic levels and with various cultural backgrounds.

All clinical sites have been chosen based upon the excellent reputation of the practicing pediatricians. Pediatric preceptors range from recent graduates to 30-year veterans, and, in several practices, students will have the opportunity to work with both.

Each pediatric site has special features, but the expectations and evaluation procedures outlined in the Ambulatory Care Selective overview apply to all pediatrics students.

One month prior to the start of your selective, contact Robin Davis, ACS Pediatric Administrative Coordinator at (919) 966-2504 regarding your assignment.

Course Listing – Psychiatry   [top]

Psychiatry is offering three ambulatory care selectives in community mental health centers with an emphasis on the treatment of mentally ill patients from both urban and rural settings.

The objectives of this selective are:

 Myra Daniel serves as Departmental Coordinator. She can be reached at (919) 966-6997.

Course Listing – Surgery   [top]

Ambulatory health care is expanding faster in surgery than in any other branch of medicine. Student involvement in this field should be a rewarding experience regardless of plans for the physician health care provider. The surgical elective is designed to acquaint the student with the office practice and common problems seen on an outpatient basis by a community or university surgeon. The student will be an active participant in the management of problems on an ambulatory basis, the evaluation of new patients, and the preoperative work-up of patients undergoing ambulatory surgical care or those requiring hospital admission. Students will be involved in postoperative follow-up care on both outpatients and inpatients. All activities will be supervised by the preceptor.

Students will spend approximately 70% of their time improving their clinical skills and 30% of their time investigating community agencies.

Students will be expected to be knowledgeable with respect to all aspects of care provided on an outpatient basis, e.g. laboratory studies, procurement of additional diagnostic procedures (i.e., radiologic), and mechanisms of procuring medical and other consultations. The student should become competent in the procurement of informed consent, patient education regarding overall surgical management, general principles of postoperative care, and counseling the patient with respect to returning to a normal lifestyle.

The student should learn the availability of financial counseling, nursing and home health care and facilities for rehabilitation. He/she can play a potentially strong role in identifying medical and social problems which may influence the perioperative care as well as the long-term results of management, i.e. depression, diabetes, drug abuse, alcoholism, social and financial factors and community resources that address these issues.

All activities of the students will be supervised and, when appropriate, countersigned by their preceptors.

Students considering taking their ACS in Surgery should consult with Dr. Colin G. Thomas, Jr. at (919) 966-4416.

Students assigned to a Surgery ACS should contact Stacey Owen, (919) 966-4781, at least one month prior to the rotation.

Updated: 05/28/2008 15:56:4205/28/2008 15:53:2405/28/2008 15:43:4705/28/2008 15:40:4705/28/2008 15:35:1805/28/2008 15:20:0705/28/2008 15:15:1505/28/2008 14:56:5605/28/2008 14:46:4305/28/2008 14:45:5505/28/2008 14:40:165/28/2008