PacMed Clinics Outpatient Subspecialty Rotations

There are three outpatient subspecialty rotations are offered through PMC: Rheum/Cardiology and Derm/Endo are two-month rotations and the Swedish Heme-Onc is a one-month rotation.

Dermatology/Endocrinology Rotation

Two enthusiastic and well-regarded teachers form the core of this rotation (Drs. Saitta and Spoonemore).  They both enjoy teaching and offer a wonderful clinical experience. In addition there are weekly Dermatology sessions at Harborview and the Puget Sound VA that nicely complement the training at PMC.

Sample Schedule:

Monday Tuesday Wednesday Thursday Friday
Derm/Spoonemore

PMC
1101 Madison

Endo/Saitta

PMC
1101 Madison

HD/Harnisch
Harborview

UW Conferences

Dermatology
Harborview

Derm/Spoonemore

PMC
1101 Madison

Endo/Saitta

PMC
1101 Madison

Derm Clinic VAPSCHSC

Endo/Saitta
PMC
Northgate

Continuity Clinic

or

Administrative

Overall Educational Purpose

The goals of the Endocrinology Clinic are to provide the resident with a solid foundation in the diagnostic evaluation, differential diagnosis, and approach to management of outpatient endocrine problems.

The goals of the Dermatology Clinic are:

  • To expose residents to common dermatological conditions as well as to recognize rare conditions.
  • To help primary care providers recognize appropriate referrals to Dermatology Specialty and to teach preventative dermatology.

Team Structure

Residents work in faculty practice with faculty attending.

Principal Teaching Methods

Endocrinology
New patients are seen by the resident and presented to the attending for discussion.  The emphasis is on understanding the various clinical presentations of endocrine disease as well as understanding the differential diagnosis and approach to managing endocrine problems. A strong emphasis is placed on developing cost-effective and high quality evaluations of these endocrine problems. Dermatology
Case discussion and review.

Educational Content

Mix of Diseases
Endocrinology
Patients presenting to the Endocrine Service display a wide variety of common endocrine problems. Residents usually see the entire spectrum of thyroid disease, as well as both type I and type II diabetics. In addition, the residents have the opportunity to evaluate adrenal and pituitary disease, endocrine hypertension, hirsutism and disorders of androgen production, hyperlipidemia, disorders of calcium metabolism, hypoglycemia, diabetes insipidus, and disorders of the gonadotropin-gonadal axis.

Dermatology
Patients seen in the Dermatology Clinic represent a broad mix of conditions, from chronic/recurring management to acute and rare diseases. Prophylaxis is stressed for skin cancer and is fairly common in our population. Chronic conditions such as eczema, acne and psoriasis are frequently seen. HIV-associated dermatology conditions are fairly frequent referrals to the HMC clinic.
Patient Characteristics
Endocrine and Dermatology
There is a wide mix of patients at PMC with a diverse ethnic background including recent immigrants seen with an interpreter, inner city residents, and military retirees and their dependents.

Approximately 10-30% of our patients are recent immigrants from countries such as Japan, China, Korea, Vietnam, Laos, Cambodia, Thailand, Mexico, Polynesia, Russia and countries of the former Soviet Union, Ethiopia, Somalia and Europe.  Residents have first-hand experience obtaining the clinical database through interpreters for these patients.

Types of Clinical Encounters
Endocrine
Primarily because of the shift of evaluating endocrinology problems to the outpatient setting, the clinical experience for residents is primarily in the endocrine clinic. Inpatient consultations, though uncommon, are shared with residents as they occur.

Dermatology
Most cases seen in the outpatient setting are non-emergent. There are often same-day referrals, especially for infectious problems or possible skin cancers.

Procedures
Endocrinology
Residents are given the opportunity to observe fine needle aspiration biopsy of thyroid nodules; however, these are attending procedures. Should an individual resident have a specific interest in learning this technique, this request would be given consideration.

Dermatology
Procedures performed in the outpatient setting include skin biopsies and scrapings, small cyst removal, acne surgery, small lesion removal, cryotherapy and intralesional injections of steroids.

Services
Endocrinology and Dermatology
The outpatient specialty clinics at PMC provide service to 18 community health clinics in the Northwest, as well as the 6 p.m.C clinics. As part of a large multi-specialty group, we have access to essentially all specialty and subspecialty consultative services, as well as auxiliary services.

Call and Weekend Responsibilities

None

Principle Educational Materials Used

Endocrinology Residents should review the most recent ADA Clinical Practice Recommendations.  Other references related to specific patients or subjects of interest will be provided.

Methods Used in Evaluating Resident and Program Performance

At the end of the rotation, the resident is evaluated in writing and their performance reviewed with them verbally.  The evaluator rates the resident on a nine-point scale in each component of clinical competence (i.e. patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident is given the opportunity to evaluate the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met.  The resident also evaluates the teaching competence of each attending.

Explicit Lines of Responsibilities for Caring of Patients on this Service

Endocrine
As an outpatient service, the ultimate responsibility for all patient care lies with the attending physician. Residents are expected to evaluate both new and return patients. Patients are seen by the resident followed by a presentation of the case to the attending physician and subsequent discussion of the diagnostic impression and plan with the patient. The residents are expected to dictate complete notes in the patient medical record, which are reviewed and counter signed by the attending physician.

Dermatology
The teaching attending is fully responsible for the dermatologic care, including follow-up of lab data, phone calls, etc. The residents do not have any of these responsibilities.

 


Rheum/Cardiology Rotation

PMC offers a wonderful opportunity to study and learn about rheumatologic diseases, from the complex and unusual to the more mundane. Under the guidance of Drs Mary Wemple and John Yuen, you will have the opportunity to interview and examine patients with a broad array of conditions. The diverse rheumatologic conditions seen at this site make for a superb experience. Dr. Mary Wemple has been chosen by her peers as one of Seattle's Top Doctors several years in a row. Rheumatology is coupled with two half days of Cardiology with Dr. John Olsen from Seattle Heart Clinic and Dr. Howard Lewis from the Seattle Cardiovascular Consultants. These two cardiologists are enthusiastic teachers and offer experiences in clinical cardiology unlike those you have had on the wards.

Sample Schedule:

Monday Tuesday Wednesday Thursday Friday

Rheum/Wemple
PMC 1101

 Rheum/Wemple
PMC 1101

Rheum/Yuen
PMC Beacon Hill

UW Conferences

 Resident’s Continuity Clinic

Rheum/Wemple
PMC 1101

Card/Olsen
Seattle Heart Clinic

Rheum/ Wemple
PMC 1101

Card/Lewis
Seattle Cardiovascular Consultants

Resident’s Continuity Clinic

Overall Educational Purpose

Rheumatology

  • To provide exposure to a broad range of systemic rheumatologic and regional musculoskeletal problems in an adult patient population, mostly clinic-based
  • To enhance skills in physical examination of the musculoskeletal system and diagnostic interpretation of rheumatologic laboratory tests
  • To learn the principles of joint aspiration and injection

Cardiology

  • To become competent in office-based evaluation and management of patients with a variety of cardiac problems
  • To improve history-taking and physical diagnosis skills related to cardiac diseases
  • To understand the impact of cardiovascular disease on patients in their daily activities
  • To become proficient in the performance of exercise treadmill tests
  • To develop a working knowledge of nuclear cardiology procedures, echocardiograms, cardiac catheterization, and cardiac pacemakers

 

Team Structure

Resident works in faculty practice with faculty attending.

Educational Content

Mix of Diseases
Rheumatology
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Spondyloarthritis and other immune-mediated systemic rheumatic disorders
  • Osteoarthritis and related degenerative musculoskeletal disorders
  • Crystal-induced joint disorders
  • Regional musculoskeletal syndromes
  • Fibromyalgia

Cardiology
A wide variety of general cardiac problems including CAD, CHF, HTN, arrhythmias, and some congenital disease, as well as exposure to ASD and PFO patients referred for closure and a large population of valvular disease patients (pre/post surgery).
Patient Characteristics
Rhuematology
Adults: 30% are military retirees and their dependents. The rest are a mix of fee-for-service, Medicare, Medicaid, charity care patients. Many referrals are from the community clinics including the International District Clinic and Seattle Indian Health Board. Cardiology
Ages 17-90, mixed ethnicity and socioeconomic status.

Types of Clinical Encounters
Rheumatology
Outpatient, scheduled appointments. New patients seen on referral from primary care providers for consultation. Follow-up appointments for patients on long-term anti-rheumatic therapy.

Cardiology
Predominantly you will see patients at scheduled office visits (6-12 per afternoon).  However, there is full opportunity to participate in pacemaker interrogation/follow-up, ETT studies, nuclear cardiac studies, echo and stress echo, and cardiac cath procedures.

Procedures
Rhuematology
Joint aspiration and injection. Tendon and bursa injection.

Cardiology
Pacemaker interrogation/follow-up, ETT studies, nuclear cardiac studies, echo and stress echo, and cardiac cath procedures.  Residents strongly encouraged to scrub one or two cases in the cath lab and assist/perform simple left hearth caths under supervision.

Services
On site laboratory, diagnostic imaging, physical therapy, pharmacy and library.

Call and Weekend Responsibilities
None

Principle Educational Materials Used

Recommended Readings
Rheumatology
Primer on the Rheumatic Disease provided to R3. On-site library with Medline access.  American College of Rheumatology teaching slides collection available.

Cardiology
Appropriate sections of Braunwald’s “Heart Disease”, pivotal reference on a case-by-case basis.

Methods Used in Evaluating Resident and Program Performance

At the end of the rotation, the resident is evaluated in writing and their performance reviewed with them.  The evaluator rates the resident on a nine-point scale in each component of clinical competence (patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident is given the opportunity to evaluate in writing the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met. The resident also evaluates the teaching competence of each attending with whom s/he has interacted for a significant amount of time.

Explicit Lines of Responsibility for Care of Patients On This Service

Direct supervision of patient care in both the outpatient clinic and hospital cases. After interviewing and examining the patient, the resident presents the case to the attending for a case-based discussion and the patient is re-examined by the attending and resident together.
For clinic patients: After interviewing and examining patients, the resident presents the case to the attending who always re-interviews and re-examines the patient to the extent necessary. Residents are responsible for a detailed chart note to be reviewed and countersigned by the attending.
For hospital patients: During weekdays only, residents answer inpatient consultation requests. After evaluation of the patient the case is presented and discussed with the attending and the resident leaves a consultation note in the chart. As a general rule this should occur within 24 hours of the receipt of the consultation. The time of inpatient rounds is arranged with the consult attending.

 


Swedish Heme-Onc

Residents work with a select group of Heme/Onc specialists during this month-long rotation. For much of the week they accompany Dr. Saul Rivkin at the Swedish Cancer Institute and at Swedish Medical Center. This is a unique opportunity to accompany a busy community oncologist as he evaluates newly diagnosed patients and determines optimal therapy, as well as caring for the complications that arise during courses of chemotherapy. In addition the resident joins three PacMed specialists in Hematology/Oncology (Drs. James Cunningham, Jane Golden and Michele Frank) for several half-day clinics per week. The PacMed Clinic and Cancer Institute are next to each other, and parking is free.

Sample Schedule:
Monday Tuesday Wednesday Thursday Friday

S Ahmed, MD
PMC
1101 Madison

V Dabhi, MD
PMC
1101 Madison

M Fer, MD
Swed
1600 E Jefferson

Conferences

Continuity Clinic

S Rivkin, MD
Swedish Cancer Inst
1221 Madison

S Ahmed, MD
PMC
1101 Madison

M Fer, MD
Swed
1600 E Jefferson

M Fer, MD
Swed
1600 E Jefferson

Continuity Clinic


Overall Educational Purpose

To expose senior residents to the outpatient aspects of clinical management of patients with cancer and hematological disorders.

Team Structure

One attending oncologist to one resident.

Principle Teaching Methods

Participation in the outpatient care of oncology and hematology patients under the direction of a teaching clinical hematologist/oncologist.

Educational Content

Mix of Diseases
The outpatients seen by the resident are either undergoing an outpatient work-up for a suspected malignancy or hematological disorder, or are receiving chemotherapy and/or other care for outpatient treatment of an established malignancy or hematological disorder.
Patient Characteristics
The patients are a broad spectrum of people; private pay patients, community clinic patients, retired military and military dependents from a health maintenance organization, and others referred to one of the four oncologists who staff the outpatient hematology/oncology rotation.
Types of Clinical Encounters
The majority of the clinical time is spent in outpatient care, although in some instances the residents accompany the attendings on their morning and evening inpatient rounds.
Procedures
Residents may perform or assist with marrow aspiration or diagnostic or therapeutic taps of effusions.
Services
The clinic practices are adjacent to Swedish Medical Center (First Hill and Cherry Hill campuses), which offers a full range of diagnostic and therapeutic options.

Principle Educational Materials Used

Recommended Readings
Each resident is encouraged to read the Heme-Onc sections of MKSAP and complete the accompanying question and answer sections before the end of the rotation. The Swedish Medical Center First Hill Library, adjacent to the Department of Medicine office, is open 10 hours a day, five days a week. Night access can be arranged for acute needs. 

Methods Used in Evaluating Resident and Program Performance

At the end of the rotation, the resident is evaluated in writing and their performance reviewed with them verbally by every attending he or she has interacted with for a significant amount of time.  The evaluator rates the resident on a nine-point scale in each component of clinical competence (i.e. patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident is given the opportunity to evaluate in writing the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met.  The resident also evaluates the teaching competence of each attending and fellow with whom s/he has interacted for a significant amount of time.

Explicit Lines of Responsibilities for Care of Patients on this Service

The relationship between the senior resident and the oncology attending is a direct one-to-one mentor-pupil.