Improving Ambulatory Training in Internal Medicine: X + Y (or Why Not?)

Abstract

The Accreditation Council for Graduate Medical Education (ACGME) requirement that internal medicine residents spend one-third of their training in an ambulatory setting has resulted in programmatic innovation across the country. The traditional weekly half-day clinic model has lost ground to the block or BX + Y^clinic model, which has gained in popularity for many reasons. Several disadvantages of the block model have been reported, however, and residency programs are caught between the threat of old and new challenges. We offer the perspectives of three large residency programs (University of Washington, Emory University, and Massachusetts General Hospital) that have successfully navigated scheduling challenges in our individual settings without implementing the block model. By sharing our innovative non-block models, we hope to demonstrate that programs can and should create the solution that fits their individual needs. D espite the Accreditation Council for Graduate Medical Education (ACGME) requirement that internal medicine residents spend one-third of their training in an ambulatory setting, graduates of internal medicine residency programs often report feeling more comfortable managing acute respiratory failure than an upper respiratory tract infection.1 As residents gravitate toward careers in inpatient-oriented subspecialties or hospital medicine, one of the reasons may be that their education is centered primarily in these arenas. Even among programs that prioritize ambulatory education, striking a balance between inpatient and outpatient training can prove to be a daunting task.The ambulatory learning model is a central component of this issue. Ambulatory education has traditionally involved a half-day continuity clinic once a week during inpatient, ICU, elective, and consult blocks. This pattern is extraordinarily challenging for residents, faculty, clinic staff, and patients. Perhaps the most common complaint is that on clinic days, residents feel as though they have two full-time jobs to complete in one, duty-hour-restricted day: caring for their full inpatient service while also caring for their panel of primary care patients.In 2009, the ACGME set a minimum of 130 half-day clinic sessions over 3 years, and required one-third of the training time to be spent in the ambulatory setting, to address the need for internists to be better trained in ambulatory medicine. These targets were difficult for many programs to achieve within the limitations of the traditional clinic template, magnifying the challenges of this model. The ACGME concomitantly added that programs were required to create strategies to reduce the inpatient-outpatient tension felt by residents, but allowed programs to individually interpret this charge.In order to achieve the above targets and minimize the conflict between inpatient and outpatient learning, innovative strategies emerged. The University of Cincinnati developed the ambulatory long-block system, with 12 continuous months of ambulatory training.3 Shalaby and colleagues at...

Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?

“…At MGH, resident physicians are supervised by staff physicians within the same clinical spaces and have access to the same resources as staff physicians including care coordination and allied health professionals. 22 Patients seen within this network are connected to specific staff physicians using a previously validated algorithm. 23 Those patients not attributed to a specific staff physician are then connected with a primary care practice.…”

Evaluation of a longitudinal subspecialty clinic for internal medicine residents

“…The LSC program was effective in achieving its objectives of providing categorical IM residents with longitudinal subspecialty career exploration, mentorship, and education in the ambulatory setting. With changing Accreditation Council for Graduate Medical Education (ACGME) program requirements calling for a subset of resident experiences to be individualized based on career plans [ 22 ] and residents spending increasing amounts of time on ambulatory rotations[ 26 ], more residency programs will likely implement curricula similar to the LSCs in the near future. While there remain some opportunities for growth, the program framework we described here can be useful for the implementation of an ambulatory subspecialty continuity experience for residents.…”

X + Y (or Why Not?)

“…In the December issue of JGIM, Ray et al examined several models of ambulatory training including an X + Y block schedule, a full-day clinic, and a hybrid clinic model. 1 Previous studies have also examined combination continuity clinics in search of a configuration that enhances patient and resident continuity, improves outcomes, and promotes high patient satisfaction. 2,3 In Table 2 of their article, Ray and colleagues highlight possible advantages and disadvantages of the three systems.…”