Challenges in an X + Y ambulatory model

Abstract

Summary Background Internal medicine training requires significant exposure to ambulatory practice. Ensuring continuity of patient care is challenging, especially with intermittent ambulatory resident assignments. A popular scheduling model is an X + Y block system where residents rotate for X weeks on inpatient rotations followed by Y weeks on ambulatory clinics. Although benefits exist with the X + Y model, it has drawbacks, particularly for continuity of care: residents struggle to obtain follow‐up test results and return patient calls promptly. To provide patients with seamless continuity the programme assigned two Managing Clinic Continuity Care Residents (MCCCRs) to cover all tasks. The MCCCRs were soon overwhelmed by the number of tasks and became dissatisfied with the workflow, however, resulting in a low task‐completion rate. Method In our 4 + 1 model residents are divided into five cohorts, we created mini‐practice groups (MPGs) consisting of one resident from each cohort. Each week the resident in the clinic is assigned to act as the Practice Clinic Continuity of Care Resident (PCCCR) for the MPG. This individual is responsible for addressing the patient tasks of the other four residents in the MPG. For optimal performance, the previous two MCCCRs are now assigned for oversight only each week. We tracked task‐completion rates weekly and surveyed residents for satisfaction. Results Following the redistribution of responsibilities, the task‐completion rates improved from 75 to 97%. The MCCCR satisfaction rate for the workflow increased from zero to 63%, and the on‐time note completion rates increased from 21 to 67%. Conclusion Modification of the X + Y model using the MPG structure ensured the timely completion of patient‐related tasks, and improved the overall experience for both patients and providers.

The Implementation of X + Y Scheduling in Combined Internal Medicine-Pediatrics Residency Programs: Practical Considerations for Program Leadership

“…Over the last decade, X + Y scheduling models have gained popularity among internal medicine residency programs [1][2][3]. X + Y scheduling, or block scheduling, refers to a system in which residents alternate between blocks of traditional resident rotations and blocks of ambulatory, primary care-focused experiences.…”

“…The authors of this study are program directors of five of the first Med-Peds programs to adopt X + Y scheduling under the AIRE pilot; in this article, we aim to use our programs' experience to describe unique considerations for Med-Peds programs and provide a guide for Med-Peds program directors considering X + Y scheduling. In so doing, we will supplement the work of others by describing more general considerations of X + Y implementation for categorical residency programs [1][2][3]. In this paper, we divide considerations for a Med-Peds program considering or planning an X + Y curriculum into four areas, each of which has unique challenges and opportunities for combined training programs (Table 1).…”