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Lai PMR, Mullin JP, Berger A, Moreland DB, Levy EI. Neurosurgical Training Requires Embracing Ambulatory Surgery Centers. Neurosurgery 2024; 95:725-727. [PMID: 38578095 DOI: 10.1227/neu.0000000000002936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 04/06/2024] Open
Affiliation(s)
- Pui Man Rosalind Lai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Buffalo , New York , USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Buffalo , New York , USA
| | - Assaf Berger
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Buffalo , New York , USA
| | - Douglas B Moreland
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Buffalo , New York , USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Buffalo , New York , USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo , New York , USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo , New York , USA
- Jacobs Institute, Buffalo , New York , USA
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Liang L, Liu X, Zhang L, Su Q. A novel model of ambulatory teaching of residents in general practice in China: a cross-sectional study. BMC MEDICAL EDUCATION 2024; 24:679. [PMID: 38898478 PMCID: PMC11186264 DOI: 10.1186/s12909-024-05647-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND This study aims to determine the satisfaction and future training needs of general practice residents participating in a novel model of ambulatory teaching aligned with the specifications for standardized residency training in outpatient management issued by the Chinese Medical Doctor Association (CMDA). METHODS A cross-sectional survey of the satisfaction and training needs was conducted among general practice residents at West China Hospital, Sichuan University. Patient characteristics and preceptors' feedback on the residents' performance were also analyzed. RESULTS The study involved 109 residents (30.28% men) and 161 patients (34.78% men; age: 52.63 ± 15.87 years). Residents reported an overall satisfaction score of 4.28 ± 0.62 with the ambulatory teaching program. Notably, residents scored lower in the Subjective-Objective-Assessment-Plan (SOAP) evaluation when encountering patients with the greater the number of medical problems (P < 0.001). Residents encountering patients with a shorter duration of illness (< 3 months) achieved higher scores than those with longer illness durations (≥ 3 months, P = 0.044). Residency general practitioners (GPs) were most challenged by applying appropriate and effective patient referrals (43/109; 39.45%). GPs expressed a strong desire to learn how to make decisions when facing challenging patient situations (4.51 ± 0.63). CONCLUSION This study suggests selecting patients with multiple comorbidities for ambulatory teaching and enhancing training on practical problem-solving abilities for GPs. The findings provide insights for the development of future ambulatory teaching programs.
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Affiliation(s)
- Lingbo Liang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China
| | - Xiangping Liu
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China
- Department of Primary Health Care, The fourth People's hospital of Dazhu County, Dazhou, 635100, China
| | - Lin Zhang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China
| | - Qiaoli Su
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China.
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Peek CJ, Allen M, Loth KA, Harper PG, Martin C, Pacala JT, Buffington A, Berge JM. Harmonizing the Tripartite Mission in Academic Family Medicine: A Longitudinal Case Example. Ann Fam Med 2024; 22:237-243. [PMID: 38806264 PMCID: PMC11237216 DOI: 10.1370/afm.3108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 12/11/2023] [Accepted: 01/16/2024] [Indexed: 05/30/2024] Open
Abstract
Academic practices and departments are defined by a tripartite mission of care, education, and research, conceived as being mutually reinforcing. But in practice, academic faculty have often experienced these 3 missions as competing rather than complementary priorities. This siloed approach has interfered with innovation as a learning health system in which the tripartite missions reinforce each other in practical ways. This paper presents a longitudinal case example of harmonizing academic missions in a large family medicine department so that missions and people interact in mutually beneficial ways to create value for patients, learners, and faculty. We describe specific experiences, implementation, and examples of harmonizing missions as a feasible strategy and culture. "Harmonized" means that no one mission subordinates or drives out the others; each mission informs and strengthens the others (quickly in practice) while faculty experience the triparate mission as a coherent whole faculty job. Because an academic department is a complex system of work and relationships, concepts for leading a complex adaptive system were employed: (1) a "good enough" vision, (2) frequent and productive interactions, and (3) a few simple rules. These helped people harmonize their work without telling them exactly what to do, when, and how. Our goal here is to highlight concrete examples of harmonizing missions as a feasible operating method, suggesting ways it builds a foundation for a learning health system and potentially improving faculty well-being.
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Affiliation(s)
- C J Peek
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Michele Allen
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Katie A Loth
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Peter G Harper
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Casey Martin
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - James T Pacala
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | | | - Jerica M Berge
- Department of Family Medicine and Adult and Child Center for Outcomes Research and Delivery Science at the University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Garrison GM, Meunier MR, Boswell CL, Greenwood JD, Nordin T, Angstman KB. Continuity of Care: A Primer for Family Medicine Residencies. Fam Med 2024; 56:76-83. [PMID: 38055847 DOI: 10.22454/fammed.2023.913197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Continuity of care has been an identifying characteristic of family medicine since its inception and is an essential ingredient for high-functioning health care teams. Many benefits, including the quadruple aim of enhancing patient experience, improving population health, reducing costs, and improving care team well-being, are ascribed to continuity of care. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) added two new continuity requirements-annual patient-sided continuity and annual resident-sided continuity-in family medicine training programs. This article reviews continuity of care as it applies to family medicine training programs. We discuss the various types of continuity and issues surrounding the measurement of continuity. A generally agreed upon definition of patient-sided and resident-sided continuity is presented to allow programs to begin to collect the necessary data. Especially within resident training programs, intricacies associated with maintaining continuity of care, such as empanelment, resident turnover, and scheduling, are discussed. The importance of right-sizing resident panels is highlighted, and a mechanism for accomplishing this is presented. The recent ACGME requirements represent a cultural shift from measuring resident experience based on volume to measuring resident continuity. This cultural shift forces family medicine training programs to adapt their various systems, policies, and procedures to emphasize continuity. We hope this manuscript's review of several facets of contuinuity, some unique to training programs, helps programs ensure compliance with the ACGME requirements.
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Affiliation(s)
| | | | | | | | - Terri Nordin
- Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI
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Carek SM, Farrow BL, Nelson V. Enhanced Scheduling to Improve Resident Continuity in a Family Medicine Teaching Clinic. Fam Med 2024; 56:115-119. [PMID: 38055854 DOI: 10.22454/fammed.2023.337984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Continuity of care is a core concept at the heart of primary care practices. Increased patient-provider continuity of care is associated with better satisfaction scores, better clinical outcomes, decreased hospitalizations and emergency department utilization, improved completion of preventive health services, adherence to medical treatment plans, and improved show rates. Compared to traditional outpatient practices, resident teaching clinics traditionally have lower rates of continuity and face unique challenges in improving continuity given the curricular demands, complex scheduling, and high turnover of providers. The objective of our study was to assess the impact of front office training and new electronic medical record (EMR) scheduling protocols on resident continuity in a family medicine teaching clinic. METHODS From July 2021 through May 2022, optimized scheduling through a provider search function in the EMR was implemented in a family medicine teaching clinic. We compared the monthly continuity rates between corresponding months in the prior year and the intervention year. RESULTS Over an 11-month implementation process, continuity for resident physicians increased from 36.4% to 64.6% (χ2=675.41, P<.001) using EMR tools and scheduling search functions to improve and sustain continuity over the study period. CONCLUSIONS This intervention to enhance continuity in a family medicine residency clinic led to rapid and sustained improvement in provider continuity. This result demonstrates that optimization of EMR scheduling with tools and protocols can improve overall continuity. This scheduling process can likely be applied to clinical sites for residency programs across disciplines.
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Affiliation(s)
- Stephen M Carek
- Prisma Health, University of South Carolina School of Medicine, Greenville, SC
| | - Brittany L Farrow
- Prisma Health, University of South Carolina School of Medicine, Greenville, SC
| | - Vicki Nelson
- Prisma Health, University of South Carolina School of Medicine, Greenville, SC
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Hersch D, Klemenhagen K, Martin C, Berg B, Adam P. Impact of Set-Day Clinic on Physician Continuity in a Family Medicine Residency Clinic. Fam Med 2023; 55:612-615. [PMID: 37540533 PMCID: PMC10622135 DOI: 10.22454/fammed.2023.329731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Continuity of care between patients and their primary care providers is associated with improved patient outcomes and experience, decreased health care costs, and improved provider well-being. Strategies to enhance continuity of care in residency programs involve electronic health record, scheduling, and panel management methods. Our study compared physician-patient continuity rates (pre and post) for one family medicine residency's implementation of a set-day clinic (SDC) scheduling model. METHODS In July 2019, Bethesda Clinic switched from a rotation-driven scheduling (RDS) model to SDC. Physicians were divided into two scheduling groups: Monday, Thursday, or Friday; or Tuesday, Wednesday, or Friday. We used visit data from two 6-month periods, October 2018 to March 2019 (RDS) and October 2021 to March 2022 (SDC), to calculate continuity using the continuity for physician formula. We used t tests to compare mean continuity rates between the RDS and SDC periods. In June 2022, faculty and residents were emailed a nine-question survey about SDC. RESULTS Adherence to the SDC model ranged from 65% to 76%. Postgraduate year (PGY) 3 residents' continuity increased significantly (P<.001) from 44% (RDS) to 56% (SDC), while PGY2 residents' continuity increased, nonsignificantly, from 38% to 43%. Among those that completed the survey, 94% of residents and 78% of faculty were in favor of SDC. CONCLUSIONS We demonstrated that SDC is feasible and well received by residents and faculty alike. Continuity was highest for PGY2 and PGY3 residents during the SDC period. Predictable clinic schedules have the potential to improve continuity in family medicine residency clinics and may improve physician well-being.
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Affiliation(s)
- Derek Hersch
- Department of Family Medicine and Community Health, University of Minnesota Medical SchoolMinneapolis, MN
| | - Kristen Klemenhagen
- Department of Family Medicine and Community Health, University of Minnesota Medical SchoolMinneapolis, MN
| | - Casey Martin
- Department of Family Medicine and Community Health, University of Minnesota Medical SchoolMinneapolis, MN
| | - Bjorn Berg
- Division of Health Policy and Management, School of Public Health, University of MinnesotaMinneapolis, MN
| | - Patricia Adam
- Department of Family Medicine and Community Health, University of Minnesota Medical SchoolMinneapolis, MN
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Zeller TA, Beben K, Kong M, Martonffy I, Patterson S, Deas W, Heo M, Keister DM. Longitudinal Interleaved Residency Training: A Consensus Definition. Fam Med 2023; 55:311-316. [PMID: 37310675 PMCID: PMC10622099 DOI: 10.22454/fammed.2023.378423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Cognitive benefits of longitudinal curricula and interleaving have been demonstrated in several disciplines. However, most residency curricula are structured in a block format. There is no consensus definition as to what constitutes a longitudinal program, making comparative research on curricular efficacy a challenge. The objective of our study was to arrive at a consensus definition of Longitudinal Interleaved Residency Training (LIRT) in family medicine. METHODS A national workgroup was convened and utilized a Delphi method between October 2021 and March 2022 to arrive at a consensus definition. RESULTS Twenty-four invitations were sent, and 18 participants initially accepted. The final workgroup (n=13) was representative of the nationwide diversity of family medicine residency programs in terms of geographic location (P=.977) and population density (P=.123). The following definition was approved: "LIRT is a curricular design and program structure that offers graduated, concurrent clinical experiences in the core competencies of the specialty. LIRT models the comprehensive scope of practice and continuity that defines the specialty; applies training methods that enhance long-term retention of knowledge, skills, and attitudes across all dimensions and locations of care delivery; and accomplishes program objectives through employment of longitudinal curricular scheduling and interleaving with spaced repetition." Additional technical criteria and definitions of terms are elucidated in the body of this article. CONCLUSIONS A representative national workgroup crafted a consensus definition of Longitudinal Interleaved Residency Training (LIRT) in family medicine, a program structure with a basis in emerging evidence-based cognitive science.
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Affiliation(s)
- T. Aaron Zeller
- Prisma Health/University of South Carolina School of Medicine–Greenville (Seneca) Family Medicine ResidencyGreenville, SC
- Prisma HealthGreenville, SC
- Clemson University School of Health Research (CUSHR)Clemson, SC
- University of South Carolina School of Medicine–GreenvilleGreenville, SC
| | - Katherine Beben
- Prisma Health/University of South Carolina School of Medicine–Greenville (Seneca) Family Medicine ResidencyGreenville, SC
- Prisma HealthGreenville, SC
- University of South Carolina School of Medicine–GreenvilleGreenville, SC
| | | | - Ildi Martonffy
- University of Wisconsin Department of Family Medicine and Community Health Madison, WI
| | - Seth Patterson
- Prisma HealthGreenville, SC
- University of South Carolina School of Medicine–GreenvilleGreenville, SC
- Prisma Health/University of South Carolina School of Medicine-Greenville (Greer) Family Medicine ResidencyGreenville, SC
| | - Weldon Deas
- Prisma Health/University of South Carolina School of Medicine–Greenville (Seneca) Family Medicine ResidencyGreenville, SC
- Prisma HealthGreenville, SC
| | - Moonseong Heo
- Department of Public Health Sciences, Clemson UniversityClemson, SC
| | - Drew M. Keister
- Lehigh Valley Health Network Department of Family MedicineAllentown, PA
- University of South Florida Morsani College of MedicineTampa, FL
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Eiff MP, Ericson A, Dinh DH, Valenzuela S, Nadeau MT, Dickinson WP, Conry C, Martin JC, Carney PA. Resident Visit Productivity and Attitudes About Continuity According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Study. Fam Med 2023; 55:225-232. [PMID: 37043182 PMCID: PMC10622023 DOI: 10.22454/fammed.2023.486345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Training models in the Length of Training Pilot (LOTP) vary. How innovations in training length affect patient visits and resident perceptions of continuity is unknown. METHODS We analyzed resident in-person patient encounters (2013-2014 through 2018-2019) for each postgraduate year (PGY) and total visits at graduation derived from the Accreditation Council for Graduate Medical Education reports for each LOTP program. We collected data on residents' perceptions of continuity from annual surveys (2015-2019). We analyzed continuous variables using independent samples t tests with unequal variance and categorical variables using χ2 tests in comparing 3-year (3YR) versus 4-year (4YR) programs. RESULTS PGY-1 and PGY-2 residents in 4YR programs saw statistically more patients than their counterparts in 3YR programs. In PGY3, 3YR program residents had statistically higher visit volume compared to 4YR program residents. Visits conducted in PGY4 ranged from 832 to 884. The additional year of training resulted in approximately 1,000 more total patient visits. Most residents in 3YR and 4YR programs rated their continuity clinic experience as somewhat or very adequate (range 86.3% to 93.7%), which did not statistically differ according to length of training. CONCLUSIONS Resident visits were significantly different at each PGY level when comparing 3YR and 4YR programs in the LOTP and the additional year of training resulted in about 1,000 more total visits. Resident perspectives on the adequacy of their continuity clinic experience appeared to not be affected by length of training. Future research should explore how the volume of patient visits performed in residency affects scope of practice and clinical preparedness.
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Affiliation(s)
| | | | | | | | - Mark T. Nadeau
- University of Texas Health Science Center at San AntonioSan Antonio, TX
| | | | | | - James C. Martin
- University of Texas Health Science Center at San AntonioSan Antonio, TX
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Forrest LL, McHugh D, MarquisEydman T. Insights for New and Developing Rural Family Medicine Residency Programs. Fam Med 2023; 55:81-88. [PMID: 36689447 PMCID: PMC10614542 DOI: 10.22454/fammed.2022.810495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Rural family medicine residency programs (RFMRPs) encounter unique hardships that threaten their sustainability and efficacy despite their recent success at addressing the rural physician shortage. The aim of this study was to explore strategies employed by RFMRP program directors from across the United States to strengthen their programs in the context of evolving paradigms in graduate medical education (GME). METHODS The authors conducted a qualitative semistructured telephone interview with 19 program directors of RFMRPs in June and July of 2020. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic content analysis. FINDINGS Two major themes emerged: (1) community enrichment and (2) the ability to evolve to meet demands. Community enrichment had five subthemes: evaluate local resources, prioritize community buy-in, design a robust continuity clinic, identify or cultivate a local physician champion, and support faculty and physician preceptors. Programs evolving to meet demands had four subthemes: frequently revisit program mission to align with scope of family medicine, redefine expectations in medical education, integrate longitudinal experiences, and implement innovation in curriculum design. CONCLUSIONS Community enrichment and programs' ability to evolve to meet demands are important attributes of a successful RFMRP. Our findings highlight strategies utilized by RFMRPs to help meet the needs of the changing landscape of rural family medicine GME and help identify best practices for developing RFMRPs.
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Affiliation(s)
- Lala L. Forrest
- Frank H. Netter MD School of Medicine, Quinnipiac UniversityNorth Haven, CT
| | - Douglas McHugh
- Department of Medical Sciences Frank H. Netter MD School of Medicine, Quinnipiac UniversityHamden, CT
| | - Traci MarquisEydman
- Department of Family Medicine Frank H. Netter MD School of Medicine, Quinnipiac UniversityHamden, CT
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Thomas DC, Frambach JM, Teunissen PW, Goldberg T, Smeenk FWJM. Learning in Tension: A Case Study Examining What Internal Medicine Residents Learn in the Ambulatory Care Setting. PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:41-49. [PMID: 36908741 PMCID: PMC9997111 DOI: 10.5334/pme.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/17/2022] [Indexed: 05/05/2023]
Abstract
Introduction Medical care of patients with complex conditions has shifted to the ambulatory setting, whereas current knowledge of resident learning is primarily based on studies from inpatient settings. Preparing trainees to adapt to this shift necessitates an understanding of what internal medicine (IM) residents currently learn during ambulatory rotations. The aim of this study is to identify what residents learn during their ambulatory care experience. Methods Using a qualitative instrumental case study design, the authors conducted separate focus groups with IM trainees (n = 15), supervisors (n = 16), and program directors (n = 5) from two IM programs in New York City, USA in 2019. Participants were invited via email, and focus group sessions were complemented by document analysis of ambulatory syllabi. Results Based on focus group commentary and document analysis, content learned in the ambulatory setting encompassed three domains; 1) patient needs, 2) the resident's role within a healthcare team, and 3) health system opportunities and limitations. Residents also learned about tensions within and between these domains including the skills needed to care for patients versus the skills acquired, a desire for ownership of patient care versus fragmented care, and time allotted versus time required. Discussion This study revealed two outcomes about what residents learn during their ambulatory care experience. First, learning content largely fell into three domains. Second, residents learned about the tensions between ideal care delivery and the realities of practice. These results highlight the imperative to better align curricula with clinical environments to meet the learning needs of residents.
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Affiliation(s)
- David C. Thomas
- Icahn School of Medicine at Mount Sinai, New York, NY, US
- Department of Medicine, Department of Medical Education and Department of Rehabilitation and Human Performance, US
| | - Janneke M. Frambach
- School of Health Professions Education (SHE), Maastricht, University, Maastricht, NL
- Department of Educational Development and Research, NL
| | - Pim W. Teunissen
- School of Health Professions Education (SHE), Maastricht, University, Maastricht, NL
- Department of Obstetrics & Gynecology, Maastricht University Medical Center, Maastricht, NL
| | - Tamara Goldberg
- Icahn School of Medicine at Mount Sinai, New York, NY, US
- Department of Medicine and Department of Medical Education, US
| | - Frank W. J. M. Smeenk
- School of Health Professions Education (SHE), Maastricht, University, Maastricht, NL
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Kashner TM, Greenberg PB, Henley SS, Bowman MA, Sanders KM. Assessing Physician Resident Contributions to Outpatient Clinical Workload. Med Care 2022; 60:709-717. [PMID: 35899991 PMCID: PMC9365263 DOI: 10.1097/mlr.0000000000001752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Graduate medical education is centered in hospitals despite a care system where patients mostly receive their care in an outpatient setting. Such gaps may exist because of inadequate funding for residency positions in community and hospital-based clinics. OBJECTIVE Determine if physician residents' contribution to outpatient workload offsets their costs for supervision, salary, and fringe benefits as residents acquire skills to become independent practitioners. RESEARCH DESIGN VA's electronic patient records from 2005 through 2018 were analyzed using generalized linear mixed models to estimate resident and staff contributions to workload in relative value units. MEASURES Resident participation rate is resident contributed workload net of supervision as a percent of total clinic workload. Productivity is per diem resident workload as a percent of per diem staff workload. Efficiency is per dollar resident workload as a percent of per dollar staff workload. Progressive independence is annual rate of change in resident productivity. RESULTS Average participation rates varied by specialty from 6% to 22%, with 11% (primary care) and 13% (psychiatry). Productivity rates ranged from 21% to 94%, with 57% (primary care) and 61% (psychiatry). Efficiency rates varied from 0.63 to 3.81, with 1.69 (primary care), 1.89 (psychiatry). Progressive independence rates varied from 2.7%/year (psychiatry) to 39.7%/year (specialty care). CONCLUSIONS Although residents rotating through most VA clinics generate revenue to cover their direct costs as they learn, some federal subsidies may be necessary to encourage hospital- and community-based clinics to accept residents from the less profitable primary care and mental health specialties.
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Affiliation(s)
- T. Michael Kashner
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
- Loma Linda University Medical School, Loma Linda, CA
| | - Paul B. Greenberg
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
- Brown University School of Medicine, Providence RI
| | - Steven S. Henley
- Loma Linda University Medical School, Loma Linda, CA
- Martingale Research Corporation, Plano, TX
| | - Marjorie A. Bowman
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
| | - Karen M. Sanders
- Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC
- Virginia Commonwealth University School of Medicine, Richmond, VI
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Fortuna RJ, Tobin DG, Sobel HG, Barrette EP, Noroha C, Laufman L, Huang X, Staggers KA, Nadkarni M, Lu LB. Perspectives of internal medicine residency clinics: A national survey of US medical directors. EDUCATION FOR HEALTH (ABINGDON, ENGLAND) 2022; 35:58-66. [PMID: 36647933 DOI: 10.4103/efh.efh_75_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited. METHODS We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US. RESULTS Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients. DISCUSSION Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.
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Affiliation(s)
- Robert J Fortuna
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Daniel G Tobin
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Halle G Sobel
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Ernie-Paul Barrette
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Craig Noroha
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Larry Laufman
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Xiaofan Huang
- Biostatics, Baylor College of Medicine, Houston, TX, USA
| | | | - Mohan Nadkarni
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lee B Lu
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Wang F, Huang YL, Ju F, Grega JC. Resident Rotation Scheduling for Categorical Internal Medicine Residency Program. IEEE Robot Autom Lett 2022. [DOI: 10.1109/lra.2022.3150515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Adam P, Hersch D, Peek CJ. Implementing Clinic First Guiding Actions Across 4 Family Medicine Residency Clinics. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:233-238. [PMID: 34039853 DOI: 10.1097/acm.0000000000004180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PROBLEM Family medicine faculty and residents have observed that continuity clinic is often unsatisfying, attributed to a lack of patient and team continuity and erratic clinic schedules pieced together after the prioritization of hospital service and rotation schedules. APPROACH In 2019, a 3-year Clinic First project, called Clinic as Curriculum (CaC), was launched across the 4 family medicine residencies of the Department of Family Medicine and Community Health, University of Minnesota Medical School. The department began publishing quarterly CaC dashboard data. Each clinic completed a baseline assessment of their performance on the 13 Building Blocks of High-Performing Primary Care. Using their baseline data, each clinic identified which block or blocks, in addition to the blocks on continuity of care and resident scheduling, to focus on. The plan is to collaboratively implement the overall and local goals using dashboard data and iterative process improvement over 3 years. OUTCOMES At baseline, clinics functioned quite well with respect to the 13 building blocks, but CaC dashboard data varied across the 4 clinics, with large variation between clinics on how frequently faculty were scheduled in the clinic and the proportion of total clinic visits seen by faculty. Resident continuity rates were low (range, 38%-47%). Level loading (consistent physician availability to meet patient demand) rates ranged from 1 to 11 days a month. Regarding resident schedules, 2 programs are moving from 4-week to 2-week inpatient blocks, and 2 programs are exploring longitudinal scheduling. One clinic will assign faculty and residents to specific clinic days. Two clinics are implementing microteams of 1 faculty and 3-4 residents. NEXT STEPS The authors plan to analyze the dashboard data longitudinally; explore microteams, team continuity, and team scheduling adherence; and develop and implement resident scheduling changes over the next 3 years.
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Affiliation(s)
- Patricia Adam
- P. Adam is vice chair for clinical affairs and associate professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Derek Hersch
- D. Hersch is research facilitator, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - C J Peek
- C.J. Peek is professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
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Holt SR, Tobin DG, Whitman L, Ellman M, Moriarty JP, Doolittle B. Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees. Am J Med 2021; 134:547-553. [PMID: 33385340 DOI: 10.1016/j.amjmed.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen R Holt
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn.
| | - Daniel G Tobin
- St. Raphael's Adult Primary Care Center of Yale-New Haven Hospital, Conn
| | - Laura Whitman
- York Street Campus Primary Care Center of Yale-New Haven Hospital, Conn
| | - Matthew Ellman
- Yale Internal Medicine Associates, Yale School of Medicine, New Haven, Conn
| | - John P Moriarty
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn
| | - Benjamin Doolittle
- Yale Internal Medicine-Pediatrics Residency Program, Yale School of Medicine, New Haven, Conn
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Coyle A. Residency Practice Transformation: Implementation of Team-Based Care in an Academic Continuity Clinic. J Grad Med Educ 2020; 12:478-484. [PMID: 32879689 PMCID: PMC7450747 DOI: 10.4300/jgme-d-19-00909.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/23/2020] [Accepted: 05/20/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Team-based primary care has the potential to improve care delivery. However, residency scheduling and precepting models make creating functional ambulatory teams challenging. OBJECTIVE We describe the team-based care transformation at a large academic internal medicine residency practice. METHODS On July 1, 2016, the program transitioned to a 6+2 schedule and the clinic was divided into teams. Residents were precepted by 2 team preceptors, social work and care coordination needs were met by team-specific staff, and front desk staff were trained on maintaining primary care physician (PCP) and team continuity. Weekly team meetings provided opportunities for proactive patient and panel management, and preclinic huddles incorporated staff into team functions. Pre-transformation (June 2016) and post-transformation (June 2017) surveys were distributed to residents (n = 131), faculty (n = 14), and staff (n = 65) to assess team functioning. Patient-PCP continuity was monitored on a quarterly basis. RESULTS Three hundred sixty-two of 420 surveys were returned (86%). The intervention was associated with significant improvements in resident satisfaction (from 3.05 baseline to 4.07 of 5, P < .001) and perceptions of teamwork (4.14 to 4.61 of 6, P < .001), with moderate to large effect sizes. Patient-PCP continuity significantly increased (45% to > 70%). While domain-specific improvements were seen for faculty and staff, no overall changes were noted in their perceptions of teamwork or team-based care. CONCLUSIONS Team-based care was implemented with significant improvements in continuity and resident satisfaction and perceptions of teamwork; however, the impact on faculty and staff was limited.
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Coyle A. A Decade of Teaching and Learning in Internal Medicine Ambulatory Education: A Scoping Review. J Grad Med Educ 2019; 11:132-142. [PMID: 31024643 PMCID: PMC6476084 DOI: 10.4300/jgme-d-18-00596.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/20/2018] [Accepted: 01/16/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Ambulatory training in internal medicine residency programs has historically been considered less robust than inpatient-focused training, which prompted a 2009 revision of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine. This revision was intended to create a balance between inpatient and outpatient training standards and to spur innovation in the ambulatory setting. OBJECTIVE We explored innovations in ambulatory education in internal medicine residency programs since the 2009 revision of the ACGME Program Requirements in Internal Medicine. METHODS The authors conducted a scoping review of the literature from 2008 to 2017, searching PubMed, ERIC, and Scopus databases. Articles related to improving educational quality of ambulatory components of US-based internal medicine residency programs were eligible for inclusion. Articles were screened for relevance and theme categorization and then divided into 6 themes: clinic redesign, curriculum development, evaluating resident practice/performance, teaching methods, program evaluation, and faculty development. Once a theme was assigned, data extraction and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI) score were completed. RESULTS A total of 967 potentially relevant articles were discovered; of those, 182 were deemed relevant and underwent full review. Most articles fell into curriculum development and clinic redesign themes. The majority of included studies were from a single institution, used nonstandardized tools, and assessed outcomes at the satisfaction or knowledge/attitude/skills levels. Few studies showed behavioral changes or patient-level outcomes. CONCLUSIONS While a rich diversity of educational innovations have occurred since the 2009 revision of the ACGME Program Requirements in Internal Medicine, there is a significant need for multi-institution studies and higher-level assessment.
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Forman JH, Robinson CH, Krein SL. Striving toward team-based continuity: provision of same-day access and continuity in academic primary care clinics. BMC Health Serv Res 2019; 19:145. [PMID: 30832649 PMCID: PMC6399842 DOI: 10.1186/s12913-019-3943-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/01/2019] [Indexed: 12/04/2022] Open
Abstract
Background An important goal of the patient-centered medical home is increasing timely access for urgent needs, while maintaining continuity. In academic primary care clinics, meeting this goal, along with training medical residents and associated professionals, is challenging. Methods The aim of this study was to understand how academic primary care clinics provide continuity to patients requesting same-day access and identify factors that may affect site-level success. We conducted qualitative interviews from December 2013–October 2014 with primary care leadership involved with residency programs at 19 Veterans Health Administration academically-affiliated medical centers. Interview recordings were transcribed verbatim. To analyze the data, we created comprehensive, structured transcript summaries for each site. Site summaries were then entered into NVivo 10 software and coded by main categories to facilitate within-case and cross-case analyses. Themes and patterns across sites were identified using matrix analysis. Results Interviewees found it challenging to provide continuity for same-day in-person visits. Most sites took a team-based approach to ensure continuity and provide coverage for same-day access, notably using NPs, PAs, and RNs in their coverage algorithms. Further, they reported several adaptations that increased multiple types of continuity for walk-in patients, urgent care between in-person visits, and follow-up care. While this study focused on longitudinal continuity, both by individual PCPs or by a team of professionals, informational continuity and continuity of supervision, as well as, to a lesser extent, relational and management continuity, were also addressed in our interviews. Finally, most interviewees reported clinic intention to provide patient-centered, team-based care and a robust educational experience for trainees, and endeavored to structure their clinics in ways that align these two missions. Conclusions In contending with the tension between providing continuity and educating new clinicians, clinics have re-conceptualized continuity as team-based, creating alternative strategies to same-day visits with a usual provider, coupled with communication strategies. Understanding the effect of these strategies on different types of continuity as well as patient experience and outcomes are key next steps in the further development and dissemination of effective models for improving continuity and the transition to team-based care in the academic clinic setting. Electronic supplementary material The online version of this article (10.1186/s12913-019-3943-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jane H Forman
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, UM North Campus Research Complex, 2800 Plymouth Road, Building 16, 3rd floor, Ann Arbor, MI, 48109-2800, USA.
| | - Claire H Robinson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, UM North Campus Research Complex, 2800 Plymouth Road, Building 16, 3rd floor, Ann Arbor, MI, 48109-2800, USA
| | - Sarah L Krein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, UM North Campus Research Complex, 2800 Plymouth Road, Building 16, 3rd floor, Ann Arbor, MI, 48109-2800, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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