Home

Fundamentals of Caring for the Ambulatory Patient 

Goals 

Upon completion of this rotation, the resident is expected to be competent in the care of low-to moderate complexity outpatients. Residents must display the requisite knowledge, skills and attitudes to provide safe, patient-centred care. In all aspects of specialist practice, the resident must be able to address issues of gender, sexual orientation, age, culture, ethnicity, spirituality and ethics in a professional manner. 

Objectives 

Medical Expert – 

1. Knowledge 

At the conclusion of the rotation, the trainee will acquire “introductory knowledge” (the ability to recognize, identify or describe principles) as demonstrated by the ability to: 

1.1 Define the components of a comprehensive psychiatric interview. 

1.2 Describe the standards of documentation required by the College and specific hospital setting.

1.3 Identify major psychotropic medication classes and their indications. 

1.4 Name the DSM-5 diagnostic criteria for common mood disorders, psychotic disorders, anxiety disorders and common comorbid substance use disorders (i.e., nicotine, alcohol, cannabis, opioid). 

At the conclusion of the rotation, the trainee will demonstrate “working knowledge” (the ability to understand the major textbooks and literature and apply it in clinical care) in the following areas as they relate to the ambulatory setting: 

1.5 Capacity / Competence • Confidentiality 

1.6 Consent • Culture and spirituality 

1.7 Stigma 

1.8 Suicide, self-harm, or harm directed towards others 

1.9 Etiology, symptoms, course of illness and treatment of: 

1.9.1 Anxiety disorders

1.9.2 Adjustment disorders and V codes (noncompliance, malingering, antisocial behavior, borderline IQ, bereavement, academic and occupational problems, cognitive decline, phase of life) 

1.9.3 Alcohol and other substance abuse disorders 

1.9.4 Delusional disorders and other psychoses 

1.9.4 Personality disorders 

1.9.5 Mood disorders 

1.9.6 Schizophrenia

Medical Expert –

2. Clinical Skills 

At the conclusion of the rotation, the trainee will demonstrate the following skills: 

Assessment and Evaluation 

2.1 Obtain necessary historical data elements including essential positives and negatives and information to clarify the course of illness and previous episodes.

2.2 Perform an appropriate and accurate mental status examination for the purposes of diagnosis and management.

2.3 Consistently screen for and identify high risk findings on mental status examination.

2.4 Demonstrate consideration of safety/risk for patient and provider in ambulatory settings (e.g., see patients during working hours, uses interview room with sufficient space, follows site specific safety practices)

2.5 Routinely conduct risk assessment and identify common modifiable and non-modifiable risk factors. 

2.6 Consistently establish and maintain an effective working relationship

Diagnostic Skills

2.7 Construct a reasonable provisional diagnosis and differential diagnosis informed by the history and current presentation. 

Comprehensive Psychiatric Management 

2.8 Develop a treatment plan in collaboration with the patient that is informed by evidence, patient preference, risk assessment and resource availability 

Pharmacotherapy 

2.9 Assess suitability for, and initiate appropriate psychopharmacological treatments for mood disorders, schizophrenia and anxiety disorders. 

2.10 Select treatments based on clinical indication and relevant evidence including practice guidelines. 

2.11 Identify common and dangerous side effects of frequently used treatments. 

2.12 Provide patient education on common and dangerous side effects of prescribed treatments. 

Documentation 

2.13 Demonstrate safe documentation practices including: timely completion of notes, medication reconciliation, patient allergies and legibility. 

2.14 Produce documentation that includes relevant risk factors and rationale for treatment plan. 

Communicator 

At the conclusion of the rotation the trainee will demonstrate the ability to: 

  1. Respect patient confidentiality, privacy and autonomy
  2. Listen effectively
  3. Be aware of and responsive to nonverbal cues
  4. Facilitate a structured clinical encounter effectively
  5. Gather information about a disease and about a patient’s beliefs, concerns, expectations and illness experience
  6. Consistently display an empathic, curious and non-judgmental stance when working with patients.
  7. Display a positive and welcoming stance towards the involvement of the family in the assessment and/or follow-up care.

Collaborator 

At the conclusion of the rotation the trainee will demonstrate the ability to: 

Ensure safe transitions in ambulatory care by consistently demonstrating the following practices: 

  1. Produce progress notes that are legible, structured and timely
  2. Identify key safety issues and plans for ongoing care in consultation reports and progress notes.
  3. Communicate treatment plans to outside care providers with timely written summaries.
  4. Participate in medication reconciliation.

Effectively work with a patient’s support network by consistently demonstrating the following practices: 

  1. Seek out and synthesize information from other sources, such as a patients’ family, caregivers and other professionals with consideration of issues of privacy and consent
  2. Regularly liaise with outside health care professionals and both formal and informal supports (e.g., social worker, consulting services, primary care provider, family and friends) as appropriate.
  3. Work with others to assess, plan, provide and integrate care for individual patients
  4. Participate in interprofessional team meetings
  5. Provide timely written updates on a patient’s care to the referral source

Leader 

At the conclusion of the rotation the trainee will demonstrate the ability to: 

Effectively prioritize clinical, educational and personal demands in order to provide safe patient care as demonstrated by: 

  1. Completion of all clinical tasks including assessments, appointments, phone calls and documentation in a timely manner.
  2. Communication of absences in a timely manner to supervisors, patients and co-workers.
  3. Obtain coverage from another physician for all absences or leaves.
  4. Communicating the coverage plan to ensure patients and other health care providers can access help when needed (e.g. inform patients and key staff)

Recognize the importance of just allocation of health care resources, balancing effectiveness, efficiency and access with optimal patient care as demonstrated by the trainee’s ability to: 

  1. Describe the different levels of care available to ambulatory patients
  2. Describe how to access different level of care in their clinical setting.
  3. Identify the average wait time for different services in their clinical setting.
  4. Discuss the role of patient safety when considering resource allocation.

Health Advocate 

At the conclusion of the rotation the trainee will demonstrate the ability to: 

  1. Describe the practice community that they serve in their ambulatory setting.
  2. Identify relevant determinants of health when assessing patients and developing treatment plans.
  3. Identify the common sources of support available to patient and their role in identifying need and facilitating access if indicated.
  4. Work with patients and their families to increase their opportunities to adopt healthy behaviours.

Scholar 

At the conclusion of the rotation the trainee will demonstrate the ability to: 

  1. Identify current best practice guidelines related to a patient’s presenting problem
  2. Access reliable medical information via electronic databases
  3. Share relevant literature with supervisor
  4. Collaboratively identify learning goals with supervisor and follow-up on progress in supervision.
  5. Access relevant supplementary literature and texts to inform case discussions in supervision.

Professional 

At the conclusion of the rotation the trainee will demonstrate the ability to: 

  1. Exhibit appropriate professional behaviours and relationships in all aspects of practice including honesty, integrity, respect for diversity, and maintenance of confidentiality.
  2. Use non-stigmatizing language in clinical discussions.
  3. Display respect in interactions with patients and colleagues.
  4. Identify and access relevant Ministry of Health, Institute and local hospital policy documents.
  5. Recognize ethical issues encountered in practice and uses supervision to reflect upon them.
  6. Display openness to feedback on lapses in professional behaviour.
  7. Identifies areas of uncertainty and seeks supervision.
  8. Discuss the impact of stress and burnout on clinical decision making.
  9. Exhibit professional behaviours in the use of technology-enabled communication including (but not limited to): email, telephone, and fax.