Residents rotate through ambulatory clinic during their “+2” weeks of the 6+2 schedule, spending approximately 12-14 weeks at TIMA each year. During their clinic blocks, each resident has a unique schedule consisting of the following half-day sessions:

• Continuity clinic – Residents see patients on their own patient panels that they grow over the three years of residency. They also see colleagues’ patients in their “Firm” for urgent concerns and post-hospital discharge visits.
• Subspeciality clinic – Residents spend 2 sessions each block in a subspeciality clinic of their choice to experience how medicine is practiced in settings outside of primary care. Interns are assigned two different subspeciality clinics in order to facilitate broad exposure.
• Triage – Residents learn telephone medicine by triaging patient concerns via telephone and portal e-messaging.
• Ambulatory Academic Half Day – Half-day session each week dedicated to the ambulatory didactic curriculum. More information below. 
• Firm – Half-day session each week for residents to work on cross-coverage tasks for their Firm colleagues, and to meet with their Firm preceptor and co-residents for small group education sessions focused on ambulatory systems-based practice. More information below.
• Community Engagement – Session dedicated to the Community Engagement curriculum, where residents can engage in self-study in their PGY-1 year, participate in the experiential Community Engagement curriculum in their PGY-2 year, and work on advocacy projects in their PGY-3 year
• Quality Improvement – Session dedicated to the Quality Improvement curriculum, where residents can work through the QI curriculum modules  and participate in a clinic-based QI project in their PGY-1 year, work on their group QI projects in their PGY-2 year, and lead clinic-based QI projects in their PGY-3 year.
• Admin - Administrative session for residents to catch up on administrative tasks, perform panel management, engage in intervisit patient care, and engage in self-study.
• Wellness – Half-day protected session without any assigned tasks where residents can schedule personal appointments, engage in social activities, or otherwise practice self-care.

The Firm System

Firms are groups of approximately 12 residents organized across the four pods to provide continuity for patients that require closer follow-up and to help cover electronic inboxes when residents are on rotations like ICU, nights, ED, and vacation. In addition to providing cross-coverage, the Firm system also provides for close oversight and mentorship through a continuity relationship with a core Firm preceptor, as well as fostering near-peer mentorship by Firm co-residents. 

Residents have a half-day Firm session each clinic week where they can work on cross-coverage tasks. They will additionally spend 30-60 minutes during each session meeting with their Firm attending and co-residents. During these meetings, the group will divvy up cross-coverage tasks and discuss difficult patient cases, and the Firm attending will present the weekly Firm curriculum. The Firm curriculum focuses on ambulatory systems-based skills such as optimizing EMR usage, navigating insurance requirements, prescribing durable medical equipment, and filling out patient forms.

The Ambulatory Academic-Half Day Curriculum

Our ambulatory curriculum is a comprehensive, three-year program that teaches and reinforces core concepts in ambulatory management of adult patients. The curriculum provides our graduates with valuable skills in clinical medicine, quality improvement, electronic medical record management, critical appraisal of medical literature, and high-value, cost-conscious care (HVCCC) that can be applied to all areas of medicine. 

During each ambulatory block, residents have two half-days dedicated to didactics, one each clinic week. Interns and residents have separate didactic days, so delivered content can be tailored to the appropriate learner level. There are no other clinical responsibilities during this time. Each half-day session includes a variety of formats, such as: 

• case-based sessions
• specialist-led interactive didactics
• communication skills training with standardized patients
• procedural skills through simulation
• physical exam skill sessions 
• resident-led ambulatory board review

In addition to protected Ambulatory Academic Half-Day didactics, residents also spend time during their ambulatory blocks participating in:

• QI curriculum 
• Community Engagement curriculum
• Systems-based practice Firm curriculum