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Alternative Approaches to Ambulatory Training: Internal Medicine Residents’ and Program Directors’ Perspectives

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ABSTRACT

BACKGROUND

Internal medicine ambulatory training redesign, including recommendations to increase ambulatory training, is a focus of national discussion. Residents’ and program directors’ perceptions about ambulatory training models are unknown.

OBJECTIVE

To describe internal medicine residents’ and program directors’ perceptions regarding ambulatory training duration, alternative ambulatory training models, and factors important for ambulatory education.

DESIGN

National cohort study.

PARTICIPANTS

Internal medicine residents (N = 14,941) and program directors (N = 222) who completed the 2007 Internal Medicine In-Training Examination (IM-ITE) Residents Questionnaire or Program Directors Survey, representing 389 US residency programs.

RESULTS

A total of 58.4% of program directors and 43.7% of residents preferred one-third or more training time in outpatient settings. Resident preferences for one-third or more outpatient training increased with higher levels of training (48.3% PGY3), female sex (52.7%), primary care program enrollment (64.8%), and anticipated outpatient-focused career, such as geriatrics. Most program directors (77.3%) and residents (58.4%) preferred training models containing weekly clinic. Although residents and program directors reported problems with competing inpatient-outpatient responsibilities (74.9% and 88.1%, respectively) and felt that absence of conflict with inpatient responsibilities is important for good outpatient training (69.4% and 74.2%, respectively), only 41.6% of residents and 22.7% of program directors supported models eliminating ambulatory sessions during inpatient rotations.

CONCLUSIONS

Residents’ and program directors’ preferences for outpatient training differ from recommendations for increased ambulatory training. Discordance was observed between reported problems with conflicting inpatient-outpatient responsibilities and preferences for models maintaining longitudinal clinic during inpatient rotations. Further study regarding benefits and barriers of ambulatory redesign is needed.

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Conflict of Interest Statement

There was no internal or external funding for this work. The authors have no conflicts of interest to report.

Author information

Authors and Affiliations

  1. Mayo Clinic College of Medicine, Rochester, MN, USA

    Kris G. Thomas MD, Colin P. West MD, PhD & Joseph C. Kolars MD

  2. American College of Physicians, Philadelphia, PA, USA

    Carol Popkave MA & Steven E. Weinberger MD

  3. University of Pennsylvania Health System, 3701 Market Street, Suite 640, Philadelphia, PA, 19104, USA

    Lisa M. Bellini MD & Jennifer R. Kogan MD

Authors
  1. Kris G. Thomas MD
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  2. Colin P. West MD, PhD
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  3. Carol Popkave MA
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  4. Lisa M. Bellini MD
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  5. Steven E. Weinberger MD
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  6. Joseph C. Kolars MD
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  7. Jennifer R. Kogan MD
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Corresponding author

Correspondence to Jennifer R. Kogan MD.

Appendix Fig. 1. 2007 Residents Questionnaire and Program Directors Survey Items Related to Outpatient Training

Appendix Fig. 1. 2007 Residents Questionnaire and Program Directors Survey Items Related to Outpatient Training

Approximately what percentage of training do you think should be spent in the outpatient (ambulatory) environment, including both general internal medicine and subspecialty ambulatory experiences?

  • ○ Less than 25%

  • ○ 25%-32%

  • ○ 33%-49%

  • ○ 50%-66%

  • ○ 67%-75%

  • ○ Over 75%

Which one of the following would be the best way (for your residents) to obtain ambulatory training, including experience in the longitudinal care of general medical patients?

Choose one.

  • ○ Weekly half-day ambulatory sessions

  • ○ Frequent block rotations (both general medicine and ambulatory subspecialties) interspersed between inpatient rotations; no ambulatory sessions while on inpatient service

  • ○ A prolonged (3 to 4 months), continuous ambulatory experience (both general medicine and ambulatory subspecialties); no ambulatory sessions while on inpatient service

  • ○ Weekly half-day ambulatory sessions plus occasional block rotations (2 to 3 months total scattered over a year)

  • ○ A combination of weekly half-day ambulatory sessions while on inpatient services interspersed with an occasional prolonged (3 to 4 months), continuous ambulatory experience with no inpatient responsibilities

When you (your residents) are on an inpatient rotation, has the presence of a weekly half-day longitudinal outpatient experience been problematic with regard to any of the following?

 

No

Yes, a little

Yes, a lot

NA

Competing inpatient and outpatient responsibilities

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Duty-hours regulations

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Fragmentation of inpatient care

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Inpatient “hand-offs”

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Interruption/delays in providing outpatient care because of inpatient responsibilities

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Travel time between clinic and inpatient units

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How important are each of the following in providing a good outpatient experience for internal medicine residents?

 

Very unimportant

Somewhat unimportant

Neutral

Somewhat important

Very important

Continuity clinic experience is considered high priority

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Cross-coverage of outpatients while on inpatient service

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Experience in a variety of outpatient settings (e.g., clinic, private practice)

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Increased subspecialty clinics

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No conflict with inpatient responsibilities

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Time with outpatients

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  1. *The above questions were asked on the Internal Medicine In-Training Examination (IM-ITE) 2007 Residents Questionnaire and Program Directors Survey to capture the opinions of internal medicine residents and program directors regarding outpatient training

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Thomas, K.G., West, C.P., Popkave, C. et al. Alternative Approaches to Ambulatory Training: Internal Medicine Residents’ and Program Directors’ Perspectives. J GEN INTERN MED 24, 904–910 (2009). https://doi.org/10.1007/s11606-009-1015-8

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  • DOI: https://doi.org/10.1007/s11606-009-1015-8

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