The 4∶1 Schedule: A Novel Template for Internal Medicine Residencies

Abstract

Background It is widely acknowledged that there is need for redesign of internal medicine training. Duty hour restrictions, an increasing focus on patient safety, the possibility of inadequate training in ambulatory care, and a growing shortage of primary care physicians are some factors that fuel this redesign movement. Intervention We implemented a 4∶1 scheduling template that alternates traditional 4-week rotations with week-long ambulatory blocks. Annually, this provides 10 blocks of traditional rotations without continuity clinic sessions and 10 weeks of ambulatory experience without inpatient responsibilities. To ensure continuous resident presence in all areas, residents are divided into 5 groups, each staggered by 1 week. Evaluation We surveyed residents and faculty before and after the intervention, with questions focused on attitudes toward ambulatory medicine and training. We also conducted focus groups with independent groups of residents and faculty, designed to assess the benefits and drawbacks of the new scheduling template and to identify areas for future improvement. Results Overall, the scheduling template minimized the conflicts between inpatient and outpatient training, promoted a stronger emphasis on ambulatory education, allowed for focused practice during traditional rotations, and enhanced perceptions of team development. By creating an immersion experience in ambulatory training, the template allowed up to 180 continuity clinic sessions during 3 years of training and provided improved educational continuity and continuity of patient care. Conclusion Separating inpatient and ambulatory education allows for enhanced modeling of the evolving practice of internists and removes some of the conflict inherent in the present system.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?

“…22,23 Given the noted strain between competing inpatient and outpatient responsibilities, 24 the continuity clinic experience for IM residents can become stressful and there is variable program compliance with ACGME ambulatory training requirements. 25 In an attempt to uncouple inpatient and outpatient training, a few new program models have developed, which include a year long ambulatory block 26 and an alternating 4:1 week inpatient to ambulatory schedule [27][28][29] that might help to support ambulatory education. Emphasizing outpatient training and education during residency while simultaneously providing protected time to practice ambulatory medicine may help retain resident interest in primary care.…”

Resident Satisfaction with Continuity Clinic and Career Choice in General Internal Medicine

“…This has been a challenging problem in most resident clinics, but recent innovations such as the ambulatory long block and the "4+1" system of inpatient to ambulatory rotations may improve continuity. 18,30 Of note, other studies have shown associations with gender and years in training and a generalist career. 31,32 Our unadjusted model demonstrated the association with gender and GIM career choice, but the relationship was not evident in the adjusted model.…”

Do medical residents perform patient-centered medical home tasks? A mixed-methods study

“…We included composite indices of learning opportunities (nine items), faculty teaching (10 items), and staff roles (eight items) by Roth et al [20]. We included two previously published items on likelihood of entering a general medicine career [21], one item on number of patients seen in a typical half-day session [22], and two items on satisfaction with the clinic [21,23] which used 5-point Likert scales ranging from ‘disagree strongly’ = 1 to ‘agree strongly’ = 5. The survey was pilot tested for face and content validity with five chief residents at one of the programs.…”