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



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.


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


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.


Residents, faculty, and administrative staff.


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


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).


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.


ambulatory training 4 + 1 model 



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)


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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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