Resident Continuity Clinic Expectations

Resident Continuity Clinic Expectations

Internal medicine specialists should have the skills necessary to manage virtually any adult medical problem. As internists, we gain experience through rigorous training during residency, including subspecialty rotations, to handle complex issues. In the ambulatory setting, preventative medicine with a focus on evidence-based guideline driven care is essential.

During your continuity clinic ambulatory experience, you're going to learn how to take care of many common and complex problems, perform outpatient procedures, and manage things that many clinics would have sent to a specialist. You'll learn, through a patient-centered and problem-driven approach, how to cost-effectively manage virtually every adult medical problem in a safe, effective, and guideline-driven manner. Your patient care will be coordinated with a board-certified internist who will provide mentorship, directly supervise, and guide you through a graduated level of autonomy and increasing responsibilities that prepares you to practice independently by the time you complete your residency.

A Typical Day in Clinic

Morning Clinic

Arrive at 8 am. It's important that you get here before patients arrive so that you can review any labs, imaging, or inbox items from the previous day. This is a good time to pour a cup of coffee and handle any outstanding items, so they don't bog you down during the day.
First patient at 8:30 am. This may be a scheduled follow-up or a work-in for an urgent problem visit. You won't always have an 8:30 am patient, and this could even happen at the last minute from a walk-in request.
Last patient during morning ½ day block is scheduled at 11 am. Since conference starts after noon, this gives you an hour to evaluate, manage, staff and hopefully write the note for your last patient of the morning.
You're doing wonderful if you're able to see all of your patients and write all of your notes before going to conference, though most people won't be able to write many (or any) notes before going to conference - especially at first. Don't worry, you'll get faster before you know it.

Afternoon Clinic

Arrive for your first patient by 1:30 pm. Last patient is scheduled no later than 4 pm. Clinic closes at 5 pm and office staff leaves.
Interns and residents are typically in clinic until about 5:30 pm finishing up notes and ensuring that patient calls and inbox items are caught up prior to going home. You can certainly go home sooner, e.g. after the last patient in the clinic has been seen, if all your clinic work is done.
Pro-tip! Don't take your work home with you. It's healthiest and best for your well-being to keep all work at work. All notes from the clinic must be completed on the same day.

Note

PGY-2 and PGY-3 Have Different Schedules and Expectations

As you would expect, an intern has a lot to learn about the flow of the clinic, ambulatory medicine, how to write notes, require longer times to staff patients, and have most of the responsibility of establishing care with new patients. Interns are going to see fewer patients, and as fund of knowledge and experience increases, you will attain a graduated level of responsibility and autonomy. As you master the common problems, patient volume is essential - allowing you to see rarer or unique conditions that allow for learning and growth. The goal is to see these numbers of patient encounters, and this often requires scheduling more patients with the anticipation of cancellations and no-shows.

PGY-1

First half of academic year: 3-4 patients per ½ day
Second half of academic year: 4-5 patients per ½ day

PGY-2

First half of academic year: 5-6 patients per ½ day
Second half of academic year: 6-7 patients per ½ day

PGY-3

7-8 patients per ½ day

Note: there are clinic scheduling nuances that affect how and why schedules are built the way they are, and this may not be readily apparent to you. Some schedules are left more open for work-ins, reduced to accommodate more new patients, or increased to accommodate many PCP follow-ups etc. Schedules will not be equitable between PGY years nor even between residents within the same PGY year. Additionally, these numbers may change depending on the number of clinic attendings in office and overall clinic patient load.

Staffing Patients with the Attending

All patients must be staffed with your assigned clinic attending, regardless of complexity or whether here for a new or patient follow-up, during the first six (6) months of intern year. These patients are coded with a "GC" modifier, which signifies to CMS that the attending physician saw and evaluated the patient with you.

After six (6) months of training, at the discretion of your attending and your own comfort level, you may start sending patients home from the clinic without the attending physically going and seeing/staffing that patient. Patients should be discussed with the attending while still in clinic or by the end of the half-day. These patients will be billed with the "GE" modifier to signify a "primary care exception" to direct supervision with CMS. This can only be done at your primary resident continuity clinic. This is to allow professional growth, autonomy, and increased patient volume to see uncommon presentations of common or rare problems, which is necessary to prepare you for independent practice.

Presenting New Patients:

In these visits, we want to be thorough and do a broad review of systems and physical exam. You do not have to present your entire exam, but we do want to "check the boxes" of going over the full medical history.

Start with the patient's name, age, and reason for establishing care. For example: "Ms. Smith is a 67 y.o. female here to establish care, she was previously followed by Dr. Doe in Miami and just moved here to live with her daughter."
Next present past medical history and medications together - every med should go with a problem. Follow this with the rest of the past medical history - family, social, surgical, and allergies.
Note pertinent review of system.
Physical exam - starting with vitals.
Assessment and plan - problem based. For example: "For essential hypertension, blood pressure is above goal today at 145/90. They check BP at home and it's about the same. Given their history of diabetes, the ADA recommends a BP goal of 130/80. They do not check ambulatory blood pressure. I gave them a blood pressure log and a printout for the DASH diet, and we agreed to start low-dose amlodipine today."

Presenting Follow-up Patients:

These are problem-based visits and, because patients often have many problems and medications in a residency clinic, we typically only discuss what is being managed today.

Start with patient's name, age, and reason for today's visit. For example: "Ms. Smith is a 67 y.o. female here for follow-up of hypertension, type 2 diabetes, and stage III obesity."
Next, present the issues you are going to discuss in a problem-based manner. For example, "For her hypertension: blood pressure is well-controlled on lisinopril 20 mg daily, no cough, lightheadedness, headache, chest pain, dyspnea, orthopnea, or lower extremity edema. Physical exam is unremarkable: vitals normal with BP 120/80, normal heart and lung sounds with no peripheral edema. I'll refill her medication without any changes and check a metabolic panel for renal function and potassium since she hasn't had labs in a year" ... Repeat for other problems.
"We will have patient follow-up in 3 months for hypertension, etc."

Patient Requests for a Specific Attending

Background: many of the patients at our teaching clinic were originally managed by our teaching attendings, and these patients were transitioned to resident PCPs. Some of these patients will ask to see a specific attending and, if they ask, you should staff that patient with the attending they requested, along with any orders and the note to co-sign.

Scheduling Patient Follow-ups

The two most important aspects of a patient follow-up: 1. Continuity between a patient and their primary care physician 2. Timing of the follow-up

A few tips for determining the appropriate patient follow-up date

Most important tip - know your schedule. You want to ensure your patients are following up with you unless it's unavoidable.
Don't knee-jerk to a routine 3-month follow-up. Consider, generically, the following situations:
Uncontrolled hypertension? 2-4 weeks
Uncontrolled anxiety or depression? 2-6 weeks
Severe new pain? 1-2 weeks
Acute on chronic heart failure? 3-14 days
Cellulitis? 1 week
Well-controlled diabetes for a long time and no recent med changes? 4-6 months
Routine 3-month follow-up but you are only in clinic 2 months from now and again 5 months from now? Consider making it a 5-month follow-up
You really need the patient to be seen again in 2 weeks and you only have an appointment 2 months from now? Look at the schedule with the front desk, find a resident with an available appointment, and call the resident who will be seeing them to sign-out your patient and plan

Writing Notes

We use smart phrases that generate an H&P and progress note template. We prefer everyone to use the same template so that all notes look similar. Your clinic attending or upper-level resident can help you acquire these templates if they're not already added to your clinic build. Note that you want to be in the "SGA Internal Med Park" Epic context for these to show up in a clinic-driven format. If you're coming from the hospital, you may be in a hospitalist context which simply customizes your build for things like autogenerating notes or billing based on where you're at.

Billing

Billing can be nuanced and complex, even for the best physicians. You don't have to be an expert at billing and, even if you were, billing rules are likely to change by the time you graduate anyways. You'll learn much about billing during your 3rd year of residency, until then the basics will suffice. Ultimately, your attending is the "billing provider"; however, your role is to choose what you think the appropriate billing is prior to closing your encounter.

99213: Low complexity (level 3) follow-up. This would be appropriate for an acute, uncomplicated illness that doesn't require treatment or just something over the counter - like viral pharyngitis. This also implies that you didn't discuss or address any other medical issues.
99214: Moderate complexity (level 4) follow-up. Probably 90% of all your follow-up encounters will be at level 4. While this can get technical, an easy way to reach this billing level is addressing two chronic problems and one prescription medication. For example, continuing metformin for type 2 diabetes and encouraging weight loss for obesity will qualify for a level 4 follow-up.
99215: High complexity (level 5) follow-up. You pretty much have to be dealing with a life-threatening illness and consider sending them to the hospital or emergency department to reach this billing code.
New visits and time-based billing: New patient visits are billed the same, other than codes are 99203, 99204, 99205. Attending physicians can also bill on time, but it must be their time - not yours.
Billing procedures: these are usually done by using a "25" modifier to add on a "significant, separate event" like a Medicare annual wellness, skin biopsy, joint injection, etc. We prefer a separate note for these things, and there are smart phrases in Epic we can get you to make this easy to document.

Managing Your Patient Phone Calls

You care for a panel of patients. You are their primary care physician. They may call to ask questions about your management, a medication you prescribed at their last appointment, get a medication refilled, get prior authorization letter written, etc. Sometimes the front desk staff or residents in clinic can help you with these, but ultimately your patients are your responsibility. This is part of the continuity of care that we train you for, and this continuity is an expectation of the ACME, your residency accrediting body. These messages will be sent to you, and regardless of your rotation you hold responsibility for ensuring that they are handled. Be diligent and ensure things that get sent to your inbox get handled, regardless of where your rotation is at the time.

Managing Your Inbox and Result Notes

Any labs, imaging orders, or other inbox messages should be managed promptly. For critical results, this is 24 hours (or sooner if is potentially life-threatening). Patient phone calls should be handled preferably same-day, within 24 hours. For routine abnormal results, patients should be notified within 7 days. You have several options for managing this:

Send results via MyChart through a result note. Be sure to write an assessment (what is going on), plan (what you're doing about it), and contact (how you let the patient know). Be sure the patient checks their MyChart before using this method, which can be done easily in Epic. Avoid sending MyChart notes for significant medical diagnosis or time-sensitive issues.
Write a result note and send it to the front desk to call for you. This is great for when patients don't have MyChart or you want to ensure they get a phone call from a nurse to know about a medication change etc. This is also a great way to reach the patient if you're writing a result note while on nights or the weekend.
Call the patient yourself. For example, an abnormal breast MRI or new diagnosis of osteoporosis or diabetes would be best discussed over the phone or calling the patient into the office for an appointment - depending on circumstances.
Ask the front desk to schedule an appointment to discuss abnormal results. Sometimes you need a long time to talk about management options and prognosis - do this in a clinic appointment if necessary.

Note: ignoring or delaying test results, phone calls, and medication refills from your patients is unprofessional, and it is harmful to the patient-physician relationship. Your clinic attending is always available to help you manage these results and patient calls should you have questions or are unsure. Documenting that you addressed these items is imperative.

Disciplinary Actions

Your ability to responsibly manage your patients is a cornerstone of your professionalism evaluation, and failure to meet expectations will result in disciplinary action at the program level. Corrective actions will be commensurate with the infraction. Most corrective actions start with verbal or informal feedback, followed by formative feedback which may or may not be in writing, and can escalate to written feedback and referral to the program director. Any of these methods of feedback are referrable to the clinical competency committee and the program director to be addressed during your semi-annual or annual evaluations. Corrective action may include remediation, probation, suspension, up to dismissal from the program.

Availability to Clinic Staff and Colleagues

Please remain in the resident workroom during office hours while in the clinic. This space is available to the front desk staff, and remaining with your other residents allows for mentoring and helping opportunities. Please refrain from using any attending physician back offices, which takes you away from your colleagues, and there may be sensitive items on the computers or in desks.

Additionally, we use Microsoft Teams for in-clinic communication. Please have this active on your work computer and/or cellphone while in the clinic. The lab or scheduling desk, for example, may have a question about an order or when to follow-up if not clear.

Dot System in Epic

You will notice colored dots next to patients' names in the clinic. This replaces the old-school way of doing things, like putting flags outside the room or lights that communicate ready status. These colors are semi-automated:

Green: once the patient is checked in and triage has obtained vitals, med rec, assisted with adding setting up care gap orders and refills, etc. - they are put in a room and marked ready for you to see them. "Green for GO!"
Blue: if a lab order, POCT, etc. is placed, the color will change to blue which signifies for the lab to get the patient. You may want to wait to sign all orders at the end of the visit so that the lab doesn't interrupt you, unless that's what you want (for a fingerstick A1c etc.)
Black: After your patient leaves the office, please manually change their color to black. This signifies to the attending and staff that the patient should no longer be here.
There are other colors (red, white) that aren't being used. We may change this in the future.

Vacation Policies

Vacation should be scheduled far enough in advance that you don't inadvertently schedule patients to see you on days you are not in clinic. Patients are entitled to see their primary care physician and should not be shuffled around to see other residents due to poor planning on our part. If you are on nights, vacation, or on some other rotation that will have you missing clinic - be sure there are no patients on your schedule. If your schedule changes unexpectedly - it is your responsibility to ensure that your schedule in the clinic is correct.

If you or on vacation or a leave of absence, you are required to assign your inbox to a partner to manage while you are gone. You must have your inbox (results, refills, calls) caught up and addressed before your last day of work

Resident Leave Request Form: Download the form here

Evaluations

You'll get a formal evaluation written by your clinic attending after your monthly rotations. You'll also get informal feedback throughout the rotation, either on a case-by-case basis and preferably with a sit-down private meeting part-way through your rotation to discuss how you are performing, areas to improve to get you to the next level, and how to achieve your future goals. Additionally, the ACME expects residents to obtain competency in six core areas prior to graduating. Your feedback will help you achieve these goals.

Revised July 1, 2024

Last update: April 22, 2026