The Impact of Block Ambulatory Scheduling on Internal Medicine Residencies: a Systematic Review

Abstract

BACKGROUND: Over the past decade, nearly half of internal medicine residencies have implemented block clinic scheduling; however, the effects on residency-related outcomes are unknown. The authors systematically reviewed the impact of block versus traditional ambulatory scheduling on residency-related outcomes, including (1) resident satisfaction, (2) resident-perceived conflict between inpatient and outpatient responsibilities, (3) ambulatory training time, (4) continuity of care, (5) patient satisfaction, and (6) patient health outcomes. METHOD: The authors reviewed the following databases: Ovid MEDLINE, Ovid MEDLINE InProcess, EBSCO CINAHL, EBSCO ERIC, and the Cochrane Library from inception through March 2017 and included studies of residency programs comparing block to traditional scheduling with at least one outcome of interest. Two authors independently extracted data on setting, participants, schedule design, and the outcomes of interest. RESULTS: Of 8139 studies, 11 studies of fair to moderate methodologic quality were included in the final analysis. Overall, block scheduling was associated with marked improvements in resident satisfaction (n = 7 studies, effect size range − 0.3 to + 0.9), resident-perceived conflict between inpatient and outpatient responsibilities (n = 5, effect size range + 0.3 to + 2.6), and available ambulatory training time (n = 5). Larger improvements occurred in programs implementing short (1 week) ambulatory blocks. However, block scheduling may result in worse physician continuity (n = 4). Block scheduling had inconsistent effects on patient continuity (n = 4), satisfaction (n = 3), and health outcomes (n = 3). DISCUSSION: Although block scheduling improves resident satisfaction, conflict between inpatient and outpatient responsibilities, and ambulatory training time, there may be important tradeoffs with worse care continuity.

Exploring the Intersections of Education and Healthcare Delivery Using a Clinical Learning Environment Framework

“…Similarly, DeWaters and colleagues reviewed the literature on ambulatory block structures in internal medicine residency programs to identify the impact of these new educational structures on what could be called the components of the clinical learning environment-namely perceptions of the experience (resident and patient satisfaction), organizational structures (conflict between inpatient and outpatient responsibilities, continuity of care), and learning/clinical outcomes (patient health outcomes). 11 The findings raise intriguing questions about the value of ambulatory blocks as clinical learning environments.…”

Teaching medicine interns minimum geriatrics competencies within a “4 + 2” schedule

“…Over the past decade, some internal medicine residency programs have adopted an “X + Y” (inpatient + ambulatory) structure in which trainees' inpatient and ambulatory rotations are scheduled in uninterrupted blocks of time. Forty‐four percent of programs reported using this type of structure on the 2015 Association of Program Directors in Internal Medicine survey, 5 which has been shown to increase residents' ambulatory training time 6 . However, there is no published literature to date describing how residency programs with an “X + Y” schedule deliver geriatrics training.…”

“…Forty-four percent of programs reported using this type of structure on the 2015 Association of Program Directors in Internal Medicine survey, 5 which has been shown to increase residents' ambulatory training time. 6 However, there is no published literature to date describing how residency programs with an "X + Y" schedule deliver geriatrics training. The Accreditation Council for Graduate Medical Education Residency Review Committee requires programs to provide "formal instruction and assigned clinical experience in geriatric medicine … directed by an ABMS-certified geriatrician," with no mandate as to the rotation length or topics taught.…”

Beyond Bagels and Yoga: Early Detection and Containment in the Burnout Epidemic

“…This special medical education issue of JGIM features two articles that describe new strategies for improving resident well-being. 1,2 Residency training has been compared to military boot camp where a group of unrelated individuals are thrown together in a high stress environment for a wellcircumscribed period of time. 3 Within this crucible, strong bonds are often forged; frequently residents spend more time with each other than with friends or family.…”

“…Broxterman and colleagues addressed all of these wellbeing factors in their EAP counseling intervention. 2 The OSCE by Zabar and colleagues 1 addressed some of these factors by empowering trainees to recognize and address a struggling colleague through a peer-to-peer interaction.…”