Journal of General Internal Medicine

, Volume 28, Issue 8, pp 1100–1104 | Cite as

Moving Forward in GME Reform: A 4 + 1 Model of Resident Ambulatory Training

  • Saima I. Chaudhry
  • Sandy Balwan
  • Karen A. Friedman
  • Suzanne Sunday
  • Basit Chaudhry
  • Deborah DiMisa
  • Alice Fornari
Original Research

Abstract

BACKGROUND

Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.

AIM

To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.

SETTING

A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.

PARTICIPANTS

Residents, faculty, and administrative staff.

PROGRAM DESCRIPTION

Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.

PROGRAM EVALUATION

A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased (p = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (p < 0.0001). Satisfaction with ambulatory training improved (p < 0.0001). Self-reported empanelment also increased (p < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (p < 0.0001).

DISCUSSION

A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.

KEY WORDS

ambulatory training 4 + 1 model 

Notes

Acknowledgements

The authors wish to acknowledge the following people for their support in the creation of the 4 + 1 model and the use of survey questions: Dr. Jeffrey Weiss, Program Director, Internal Medicine Residency at Tulane University; Dr. Marc Shalaby, Program Director, Internal Medicine Residency at Lehigh Valley; and Dr. Linda Roth, Department of Family Medicine, Wayne State University.

The authors would also like to thank the residents, chief residents, and administrative staff of the Hofstra North Shore LIJ IM Residency Program for their flexibility in transitioning to a new model of residency training and Rinkal Sundhani for her editorial assistance with this manuscript.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2013_2387_MOESM1_ESM.docx (34 kb)
ESM 1 (DOCX 33 kb)

REFERENCES

  1. 1.
    Horwitz RI, Kassirer JP, Holmboe ES, et al. Internal medicine residency redesign: proposal of the Internal Medicine Working Group. Am J Med. 2011;124:806–12.PubMedCrossRefGoogle Scholar
  2. 2.
    Holmboe ES, Bowen JL, Green M, Gregg J, et al. Reforming internal medicine residency training. A report from the Society of General Internal Medicine’s task force for residency reform. J Gen Intern Med. 2005;20:1165–72.PubMedCrossRefGoogle Scholar
  3. 3.
    Medicare Payment Advisory Commission. Report to Congress: Improving incentives in Medicare (June 2009). Available at: http://www.medpac.gov/document_TOC.cfm?id=576. Accessed February 10, 2013.
  4. 4.
    Wynn BO, Guarino C, Morse L, Cho M. Alternative ways of financing graduate medical education. Report no. WR-369- ASPE. Santa Monica: RAND Corporation; 2006.Google Scholar
  5. 5.
    Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Residency Education in Internal Medicine. Available at http://www.acgme.org/acgmeweb/tabid/134/ProgramandInstitutionalGuidelines/MedicalAccreditation/InternalMedicine.aspx. Accessed February 10, 2013.
  6. 6.
    Mariotti JL, Shalaby M, Fitzgibbons JP. The 4∶1 schedule: a novel template for internal medicine residencies. J Grad Med Educ. 2010;2:541–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Warm EJ. Interval examination: the ambulatory long block. J Gen Intern Med. 2010;25:750–2.PubMedCrossRefGoogle Scholar
  8. 8.
    Dobbie A, Rhodes M, Tysinger JW, Freeman J. Using a modified nominal group technique as a curriculum evaluation tool. Fam Med. 2004;36:402–6.PubMedGoogle Scholar
  9. 9.
    Roth LM, Severson RK, Probst JC, Monsur JC, Markova T, Kushner SA, Schenk M. Exploring physician and staff perceptions of the learning environment in ambulatory residency clinics. Fam Med. 2006;38:177–84.PubMedGoogle Scholar
  10. 10.
    Thomas KG, West CP, Popkave C, Bellini LM, Weinberger SE, Kolars JC, Kogan JR. Alternative approaches to ambulatory training: internal medicine residents’ and program directors’ perspectives. J Gen Intern Med. 2009;24:904–10.PubMedCrossRefGoogle Scholar
  11. 11.
    Sisson SD, Boonyasai R, Baker-Genaw K, Silverstein J. Continuity clinic satisfaction and valuation in residency training. J Gen Intern Med. 2007;22:1704–10.PubMedCrossRefGoogle Scholar
  12. 12.
    Skeff KM, Stratos GA, Bergen MR. Evaluation of a medical faculty development program: a comparison of traditional pre/post and retrospective pre/post self-assessment ratings. Eval Health Prof. 1992; 15:350–366.Google Scholar
  13. 13.
    Bowen JL, Stearns JA, Dohner C, Blackman J, Simpson D. Defining and evaluating quality for ambulatory care educational programs. Acad Med. 1997;72:506–10.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Saima I. Chaudhry
    • 1
    • 6
  • Sandy Balwan
    • 2
    • 6
  • Karen A. Friedman
    • 1
    • 6
  • Suzanne Sunday
    • 3
    • 6
  • Basit Chaudhry
    • 4
  • Deborah DiMisa
    • 1
    • 2
  • Alice Fornari
    • 5
    • 6
  1. 1.Division of Hospital MedicineNorth Shore LIJ Health SystemGreat NeckUSA
  2. 2.Division of General Internal MedicineNorth Shore LIJ Health SystemGreat NeckUSA
  3. 3.Department of PsychiatryNorth Shore LIJ Health SystemGreat NeckUSA
  4. 4.IBM ResearchWestchesterUSA
  5. 5.Office of Academic Affairs, North Shore LIJ Health SystemGreat NeckUSA
  6. 6.Hofstra North Shore LIJ School of MedicineHempsteadUSA

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