Ambulatory office organization for internal medicine resident medical education

Perspectives of internal medicine residency clinics: A national survey of US medical directors

BACKGROUND

Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited.

METHODS

We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US.

RESULTS

Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients.

DISCUSSION

Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.

A narrative review of ambulatory care education in Canadian internal medicine

BACKGROUND

The Canadian healthcare system faces increasing patient volumes and complexity amidst funding constraints. Ambulatory care offers a potential solution to some of these challenges. Despite growing emphasis on the provision of ambulatory care, there has been a relative paucity of ambulatory care training curricula within Canadian internal medicine residency programs. We conducted a narrative review to understand the current state of knowledge on postgraduate ambulatory care education (ACE), in order to frame a research agenda for Canadian Internal Medicine ACE.

METHODS

We searched OVID Medline, Embase, and PsycINFO for articles that included the concepts of ambulatory care and medical or health professions education from 2005-2015. After sorting for inclusion/exclusion, we analyzed 30 articles, looking for dominant claims about ACE in Internal Medicine literature.

RESULTS

We found three claims. First, ACE is considered to be a necessary component of medical training because of its distinction from inpatient learning environments. Second, current models of ambulatory care clinics do not meet residency education needs. Third, ACE presents opportunities to develop non-medical expert roles.

CONCLUSIONS

The findings of our narrative review highlight a need for additional research regarding ACE in Canada to inform optimal ambulatory internal medicine training structures and alignment of educational and societal needs.

Residency Practice Transformation: Implementation of Team-Based Care in an Academic Continuity Clinic

BACKGROUND

Team-based primary care has the potential to improve care delivery. However, residency scheduling and precepting models make creating functional ambulatory teams challenging.

OBJECTIVE

We describe the team-based care transformation at a large academic internal medicine residency practice.

METHODS

On July 1, 2016, the program transitioned to a 6+2 schedule and the clinic was divided into teams. Residents were precepted by 2 team preceptors, social work and care coordination needs were met by team-specific staff, and front desk staff were trained on maintaining primary care physician (PCP) and team continuity. Weekly team meetings provided opportunities for proactive patient and panel management, and preclinic huddles incorporated staff into team functions. Pre-transformation (June 2016) and post-transformation (June 2017) surveys were distributed to residents (n = 131), faculty (n = 14), and staff (n = 65) to assess team functioning. Patient-PCP continuity was monitored on a quarterly basis.

RESULTS

Three hundred sixty-two of 420 surveys were returned (86%). The intervention was associated with significant improvements in resident satisfaction (from 3.05 baseline to 4.07 of 5, P < .001) and perceptions of teamwork (4.14 to 4.61 of 6, P < .001), with moderate to large effect sizes. Patient-PCP continuity significantly increased (45% to > 70%). While domain-specific improvements were seen for faculty and staff, no overall changes were noted in their perceptions of teamwork or team-based care.

CONCLUSIONS

Team-based care was implemented with significant improvements in continuity and resident satisfaction and perceptions of teamwork; however, the impact on faculty and staff was limited.

Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step

BACKGROUND

The patient-centered medical home (PCMH) is an accepted framework for delivering high-quality primary care, prompting many residencies to transform their practices into PCMHs. Few studies have assessed the impact of these changes on residents' and faculty members' PCMH attitudes, knowledge, and skills. The family medicine program at Brown University achieved Level 3 PCMH accreditation in 2010, with training relying primarily on situated learning through immersion in PCMH practice, supplemented by didactics and a few focused clinical activities.

OBJECTIVE

To assess PCMH knowledge and attitudes after Level 3 PCMH accreditation and to identify additional educational needs.

METHODS

We used a qualitative approach, with semistructured, individual interviews with 12 of the program's 13 postgraduate year 3 residents and 17 of 19 core faculty. Questions assessed PCMH knowledge, attitudes, and preparedness for practicing, teaching, and leading within a PCMH. Interviews were analyzed using the immersion/crystallization method.

RESULTS

Residents and faculty generally had positive attitudes toward PCMH. However, many expressed concerns that they lacked specific PCMH knowledge, and felt inadequately prepared to implement PCMH principles into their future practice or teaching. Some exceptions were faculty and resident leaders who were actively involved in the PCMH transformation. Barriers included lack of time and central roles in PCMH activities.

CONCLUSIONS

Practicing in a certified PCMH training program, with passive PCMH roles and supplemental didactics, appears inadequate in preparing residents and faculty for practice or teaching in a PCMH. Purposeful curricular design and evaluation, with faculty development, may be needed to prepare the future leaders of primary care.

Using a resident discharge clinic for resident education and patient care: a feasibility study

BACKGROUND

Many patients in internal medicine resident continuity clinics experience difficulty accessing care, making posthospitalization ambulatory follow-up challenging. Experiential learning in care transitions is also lacking for residents.

OBJECTIVE

We sought to assess the feasibility and impact of a weekly Resident Discharge Clinic (RDC) in increasing access to early posthospitalization follow-up and providing learning opportunities for residents.

METHODS

We staffed the RDC with an ambulatory block resident, an internal medicine preceptor, and a clinical pharmacist. We assessed time to posthospitalization follow-up, readmission rates, and resident perceptions of postdischarge care for resident-clinic patients, comparing data before and after RDC implementation.

RESULTS

There were 636 discharges in the baseline group, 662 during the intervention period, and 56 in the RDC group. Six months after RDC implementation, the percentage of discharged resident-clinic patients with follow-up within 7 days improved from 6.6% at baseline to 9.7% (P  =  .04). The mean interval to the posthospitalization follow-up appointment in the RDC group was 7.4 days compared with 33.9 days in the baseline group (P < .001). The percentage of surveyed residents (n  =  72) who agreed that early follow-up was easy to arrange increased from 21% to 77% (P < .001). There was no significant decrease in the 30-day readmission rate for patients in the RDC group (18.1% versus 12.5%, P  =  .29).

CONCLUSIONS

The RDC was easily implemented, increased access to timely posthospitalization follow-up, and provided a platform for resident learning about care transitions.

Clinic design, key practice metrics, and resident satisfaction in internal medicine continuity clinics: findings of the educational innovations project ambulatory collaborative

BACKGROUND

Internal medicine programs are redesigning ambulatory training to improve the resident experience and answer the challenges of conflicting clinical responsibilities. However, little is known about the effect of clinic redesign on residents' satisfaction.

OBJECTIVE

We assessed residents' satisfaction with different resident continuity clinic models in programs participating in the Educational Innovations Project Ambulatory Collaborative (EPAC).

METHODS

A total of 713 internal medicine residents from 12 institutions in the EPAC participated in this cross-sectional study. Each program completed a detailed curriculum questionnaire and tracked practice metrics for participating residents. Residents completed a 3-part satisfaction survey based on the Veterans Affairs Learners' Perception Survey, with additional questions addressing residents' perceptions of the continuous healing relationship and conflicting duties across care settings.

RESULTS

THREE CLINIC MODELS WERE IDENTIFIED: traditional weekly experience, combination model with weekly experience plus concentrated ambulatory rotations, and a block model with distinct inpatient and ambulatory blocks. The satisfaction survey showed block models had less conflict between inpatient and outpatient duties than traditional and combination models. Residents' perceptions of the continuous healing relationship was higher in combination models. In secondary analyses, the continuity for physician measure was correlated with residents' perceptions of the continuous healing relationship. Panel size and workload did not have an effect on residents' overall personal experience.

CONCLUSIONS

Block models successfully minimize conflict across care settings without sacrificing overall resident satisfaction or resident perception of the continuous healing relationship. However, resident perception of the continuous healing relationship was higher in combination models.

The learners' perceptions survey-primary care: assessing resident perceptions of internal medicine continuity clinics and patient-centered care

BACKGROUND

In 2010, the Department of Veterans Affairs (VA) implemented a national patient-centered care initiative that organized primary care into interdisciplinary teams of health care professionals to provide patient-centered, continuous, and coordinated care.

OBJECTIVE

We assessed the discriminate validity of the Learners' Perceptions Survey-Primary Care (LPS-PC), a tool designed to measure residents' perceptions about their primary and patient-centered care experiences.

METHODS

Between October 2010 and June 2011, the LPS-PC was administered to Loma Linda University Medical Center internal medicine residents assigned to continuity clinics at the VA Loma Linda Healthcare System (VALLHCS), a university setting, or the county hospital. Adjusted differences in satisfaction ratings across settings and over domains (patient- and family-centered care, faculty and preceptors, learning, clinical, work and physical environments, and personal experience) were computed using a generalized linear model.

RESULTS

Our response rate was 86% (77 of 90). Residents were more satisfied with patient- and family-centered care at the VALLHCS than at either the university or county (P < .001). However, faculty and preceptors (odds ratio [OR]  =  1.53), physical (OR  =  1.29), and learning (OR  =  1.28) environments had more impact on overall resident satisfaction than patient- and family-centered care (OR  =  1.08).

CONCLUSIONS

The LPS-PC demonstrated discriminate validity to assess residents' perceptions of their patient-centered clinical training experience across outpatient primary care settings at an internal medicine residency program. The largest difference in scores was the patient- and family-centered care domain, in which residents rated the VALLHCS much higher than the university or county sites.

Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents

INTRODUCTION

The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.

AIM

We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?

PROGRAM DESCRIPTION

The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).

RESULTS

The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.

DISCUSSION

The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Resident education in free clinics: an internal medicine continuity clinic experience

BACKGROUND

Most internal medicine (IM) residency programs provide ambulatory training in academic medical centers. Community-based ambulatory training has been suggested to improve ambulatory and primary care education. Free clinics offer another potential training setting, but there have been few reports about the experience of IM residents in free clinics.

OBJECTIVE

We assessed the feasibility and acceptability of inclusion of an ambulatory rotation in a free clinic and IM residency curriculum and the advantages of the free clinic setting over the traditional ambulatory clinic model.

METHODS

In 2010, the University of Chicago Internal Medicine Residency Program partnered with a free clinic in order to establish a community-based continuity clinic experience. To assess the feasibility of this innovation, 16 residents were surveyed 9 months after implementation of the clinic to determine satisfaction, perceived preparation to address common medical conditions, and attitudes toward the underserved care population. A subset of these responses was compared to responses from residents in the traditional clinic model.

RESULTS

Residents in the free clinic rotation were more satisfied and perceived they were more prepared to work in low-resource settings and reported similar levels of preparation regarding common outpatient conditions than residents in a traditional continuity clinic format. They reported increased future likelihood of working in an underserved clinic.

CONCLUSIONS

Our exploratory study suggests free clinics may be an effective platform for community-based continuity clinic training.

Update in internal medicine residency education: a review of the literature in 2010 and 2011

BACKGROUND

Evidence-based practice in education requires high-quality evidence, and many in the medical education community have called for an improvement in the methodological quality of education research.

OBJECTIVE

Our aim was to use a valid measure of medical education research quality to highlight the methodological quality of research publications and provide an overview of the recent internal medicine (IM) residency literature.

METHODS

We searched MEDLINE and PreMEDLINE to identify English-language articles published in the United States and Canada between January 1, 2010, and December 31, 2011, focusing on IM residency education. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), which has demonstrated reliability and validity. Qualitative articles were excluded. Articles were ranked by quality score, and the top 25% were examined for common themes, and 2 articles within each theme were selected for in-depth presentation.

RESULTS

The search identified 731 abstracts of which 223 articles met our inclusion criteria. The mean (±SD) MERSQI score of the 223 studies included in the review was 11.07 (±2.48). Quality scores were highest for data analysis (2.70) and lowest for study design (1.41) and validity (1.29). The themes identified included resident well-being, duty hours and resident workload, career decisions and gender, simulation medicine, and patient-centered outcomes.

CONCLUSIONS

Our review provides an overview of the IM medical education literature for 2010-2011, highlighting 5 themes of interest to the medical education community. Study design and validity are 2 areas where improvements in methodological quality are needed, and authors should consider these when designing research protocols.

Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs

BACKGROUND

Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.

OBJECTIVE

To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff

DESIGN

Retrospective cohort

PARTICIPANTS

Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009-2011. PGY2 IM residents surveyed from 2010-2011.

MEASUREMENTS

Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.

RESULTS

Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P<0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p<0.001) and those lost to follow-up (21 % vs. 17 % NSR, p=0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as "theirs" until they are seen by them in clinic.

CONCLUSIONS

While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.