Restoring Emphasis on Ambulatory Internal Medicine Training—The 3∶1 Model

Abstract

Background Resident dissatisfaction in ambulatory care training has prompted the need for new scheduling models that support a positive learning climate. Intervention We instituted a 3∶1 scheduling model for postgraduate year (PGY)–2 and PGY-3 residents. We hypothesized this model would provide a more structured ambulatory educational atmosphere, better continuity of care, and more exposure to subspecialty outpatient medicine. This model would also eliminate conflict with inpatient duties and contribute to enhance residents′ satisfaction with ambulatory medicine and their ambulatory education experience. The model used weeklong ambulatory blocks every fourth week, consisting of morning continuity clinic and afternoon subspecialty clinics. The PGY-1 residents maintained a traditional schedule. Results Residents were surveyed regarding their ambulatory experience, with an overall response rate of 73 of 80 (91%). The PGY-2 and PGY-3 responses were analyzed descriptively and compared with PGY-1 responses. Residents reported that the 3∶1 model positively affected their satisfaction with residency training in general, their satisfaction with outpatient/primary care training, and their outpatient/clinic educational experience. Residents in the 3∶1 model perceived improvements in continuity of care and in the quality of care they provided for patients. The experience in ambulatory subspecialty training was positive. Conclusions A 3∶1 scheduling model appears to mitigate some of the conflict between inpatient and outpatient duties. Residents agreed the new model promoted an improved ambulatory experience.

Factors Affecting Resident Satisfaction in Continuity Clinic—a Systematic Review

“…Programmatic restructuring interventions described by Harrison et al, 12 Chaudhry et al, 13 Warm et al,, 17 and Lofgren and Mladenovic 15 all resulted in statistically significant increases in resident satisfaction. In contrast, the restructuring intervention described by Wieland et al 18 did not influence resident satisfaction.…”

“…1). While most studies evaluated a single residency program (Barnett et al, 11 Harrison et al, 12 Chaudhry et al, 13 Hochman et al, 14 Lofgren et al, 15 Roth et al, 16 Warm et al, 17 Wieland et al 18 ), two studies each evaluated three residency programs (Sisson et al 19 and Percoralo et al 1 ) and one study evaluated 36 internal medicine programs (Serwint et al 20 ). There was no uniform survey tool used to assess satisfaction among this group of studies.…”

“…In this model, PGY2 and PGY3 residents scheduled patients into one afternoon clinic session per week no matter the inpatient rotation. In contrast to this traditional model, Harrison et al 12 and Chaudhry et al 13 created a 3:1 and 4:1 scheduling model, respectively, representing the ratio of consecutive inpatient to outpatient weeks assigned to residents. During the 1-week ambulatory portion, residents spent each morning in continuity clinic and each afternoon in a subspecialty clinic.…”

A Decade of Teaching and Learning in Internal Medicine Ambulatory Education: A Scoping Review

“…[29][30][31] Several studies focused on resident satisfaction with an overall trend toward improvement in reducing inpatient-outpatient conflict 30,[32][33][34][35] and resident satisfaction with ambulatory education, 30,33,36 but no studies found an increase in the desire to pursue primary care careers. 29,32,36 Only 2 studies evaluated improvement in quality of care in X þ Y schedules with mixed results. 31,37 Shalaby and colleagues 38 provided a practical review of crafting X þ Y schedules.…”

An Interactive Ambulatory Nephrology Curriculum for Internal Medicine Interns: Design, Implementation, and Participant Feedback

“…With the introduction of duty hour restrictions and emphasis on improved ambulatory training (16), many internal medicine residency programs have undertaken substantial scheduling changes (17–19), resulting in increased resident exposure to multispecialty outpatient care (18). The University of Pennsylvania internal medicine residency program recently adopted a 6+2 scheduling model.…”