PGY 2/3 Long Block

The Long Block begins in the 17th month of residency and continues for 12 consecutive months.

In developing our model, we felt that one year of true continuity in the ambulatory center would be better for care and education than three years of sporadic interactions.

The results have been extremely positive. Our work was cited in a New England Journal of Medicine article entitled, Experiments in Continuity — Rethinking Residency Training in Ambulatory Care.

Other recognition includes:

• Winner of the American Association of Medical College’s Readiness for Reform Innovations Challenge
• Winner of the Society of General Internal Medicine’s (SGIM) National Clinical Practice Innovation Award
• Invited Participant in American Board of Internal Medicine Foundation Forum's Transforming Medical Education and Training: Meeting the Needs of Patients and Society
• Featured practice in American Association of Medical College’s Monograph Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery
• Site visited by a sitting Governor, and 2 members of Congress
  

During the Long Block, you will transition from inpatient-based rotations to an expanded outpatient experience and you will take care of approximately 200 patients as part of your primary care panel. We will prepare for this work via our innovative Ambulatory Boot Camp program.

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 focus on one field of medicine (e.g. cardiology) or choose a broad set of electives -- it's up to you. You will work with your mentors and coaches to determine the best schedule that meets your professional needs. In addition, you can have up to three months dedicated time for research, and you will have 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, women's health specialists, and numerous others. The facility also provides access to a laboratory and pharmacy.

Most of the patients 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 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.  In 2019, approximately 22% of the clinic’s 2000 patients with diabetes had a HgA1c > 9%. Over the past three years, the focus of our quality improvement and population health efforts have been geared at reducing this rate, and as of late 2022 we had reached an all time low approaching 12%. We are extremely proud of this work.

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 by participating in the IMPACT Quality Improvement Pathway. 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 patients with diabetes who have 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. 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.