Journal of General Internal Medicine

, Volume 20, Issue 12, pp 1181–1187

Changing habits of practice

Transforming internal medicine residency education in ambulatory settings
  • Judith L. Bowen
  • Stephen M. Salerno
  • John K. Chamberlain
  • Elizabeth Eckstrom
  • Helen L. Chen
  • Suzanne Brandenburg
Internal Medicine Residency Reform: Task Force Report


PURPOSE: The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.

METHODS: The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.

RESULTS: Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.

CONCLUSION: This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident’s level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

Key Words

ambulatory graduate medical education curriculum faculty development internal medicine 


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  1. 1.
    Internal Medicine Residency Program Requirements. Scholar
  2. 2.
    Whitcomb ME, Cohen JJ. The future of primary care medicine. New Engl J Med. 2004;351:710–2.PubMedCrossRefGoogle Scholar
  3. 3.
    Cantor JC, Baker LC, Hughes RG. Preparedness for practice: young physicians’ views of their professional education. JAMA. 1993;270:1035–40.PubMedCrossRefGoogle Scholar
  4. 4.
    Wiest FC, Ferris TG, Gokhale M, Campbell EG, Weissman JS, Blumenthal D. Preparedness of internal medicine and family practice residents for treating common conditions. JAMA. 2002;288:2609–14.PubMedCrossRefGoogle Scholar
  5. 5.
    Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA. 2001;286:1027–34.PubMedCrossRefGoogle Scholar
  6. 6.
    Zandbelt LC, Smets EM, Oort FJ, Godfried MH, de Haes HC. Satisfaction with the outpatient encounter. A comparison of patient’s and physician’s views. J Gen Int Med. 2004;19:1088–95.CrossRefGoogle Scholar
  7. 7.
    Barnett DR, Bass PF 3rd, Griffith CH 3rd, Candill TS, Wilson JF. Determinants of resident satisfaction with patients in their continuity clinic. J Gen Intern Med. 2004;19:456–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Hoellein AR, Feddock CA, Griffith CH 3rd, et al. Are continuity clinic patients less satisfied when the resident is postcall? J Gen Intern Med. 2004;19:562–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Kolb DA. Experiential Learning. Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall; 1984.Google Scholar
  10. 10.
    Smith CS, Irby DM. Experience and reflection in ambulatory settings. Acad Med. 1997;72:32–5.PubMedGoogle Scholar
  11. 11.
    Gruppen LD. Implications of cognitive research for ambulatory care education. Acad Med. 1997;72:117–20.PubMedCrossRefGoogle Scholar
  12. 12.
    Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on medical expertise: theory and implications. Acad Med. 1990;65:611–21.PubMedCrossRefGoogle Scholar
  13. 13.
    Bordage G. Elaborated knowledge: a key to successful diagnostic thinking. Acad Med. 1994;69:883–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Bowen JL, Carline JD. Learning in the social context of ambulatory care clinics. Acad Med. 1997;72:187–90.PubMedCrossRefGoogle Scholar
  15. 15.
    Irby D. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med. 1995;70:898–931.PubMedCrossRefGoogle Scholar
  16. 16.
    Bowen JL, Irby DM. Assessing quality and costs of education in the ambulatory setting: a review of the literature. Acad Med. 2002;77:621–80.PubMedCrossRefGoogle Scholar
  17. 17.
    Barrison AF, Smith C, Oviedo J, Heeren T, Schroy PC III. Colorectal cancer screening and familial risk: a survey of IM residents’ knowledge and practice patterns. Am J Gastroenterol. 2003;98:1410–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Borum ML. A comparison of smoking cessation efforts in African Americans by resident physicians in a traditional and primary care internal medicine residency. J Natl Med Assoc. 2000;92:131–5.PubMedGoogle Scholar
  19. 19.
    Delnevo CD, Hausman AJ. Injury prevention counseling among residents of internal medicine. Am J Prev Med. 2000;19:63–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Delnevo CD, Steinberg MD, Abatemarco DJ, Hausman AJ. Correlates of clinical preventive practices among internal medicine residents. Prev Med. 2003;36:645–51.PubMedCrossRefGoogle Scholar
  21. 21.
    Knight RA, Remington PL. Training internal medicine residents to screen for domestic violence. J Women’s Health Gender-based Med. 2000;9:167–74.CrossRefGoogle Scholar
  22. 22.
    Rogers LQ, Bailey JE, Gutin B, et al. Teaching resident physicians to provide exercise counseling: a needs assessment. Acad Med. 2002;77:841.PubMedCrossRefGoogle Scholar
  23. 23.
    Zack DL, DiBaise JK, Quigley EM, Roy HK. Colorectal cancer screening compliance by medicine residents: perceived and actual. Am. J Gastroenterology. 2001;96:3004–8.CrossRefGoogle Scholar
  24. 24.
    Kogan JR, Reynolds EE, Shea JA. Effectiveness of report cards based on chart audit of residents’ adherence to practice guidelines on practice performance: a randomized controlled trial. Teach Learn Med. 2003;15:25–30.PubMedCrossRefGoogle Scholar
  25. 25.
    Sharma VK, Corder FA, Raufman JP, Sharma P, Fennerty MB, Howden CW. Survey of internal medicine residents’ use of the fecal occult blood test and their understanding of colorectal cancer screening and surveillance. Am J Gastroenterol. 2000;95:2068–73.PubMedCrossRefGoogle Scholar
  26. 26.
    Chin HP, Guillermo G, Prakken S, Eisendrath S. Psychiatric training in primary care medicine residency programs. A national survey. Psychosomatics. 2000;41:412–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Gaufberg EH, Joseph RC, Pels RJ, Wyshak G, Wieman D, Nadelson CC. Psychosocial training in U.S. internal medicine and family practice residency programs. Acad Med. 2001;76:738–42.PubMedCrossRefGoogle Scholar
  28. 28.
    Callahan EJ, Bertakis KD, Azari R, Robbins JA, Helms LJ, Chang DW. The influence of patient age on primary care resident physician-patient interactions. J Am Geriatric Soc. 2000;48:30–5.Google Scholar
  29. 29.
    Yancy WS Jr., Macpherson DS, Hanusa BH, et al. Patient satisfaction in resident and attending ambulatory care clinics. J Gen Intern Med. 2001;16:755–62.PubMedCrossRefGoogle Scholar
  30. 30.
    Boutin-Foster C, Charlson ME. Problematic resident-patient relationships: the patient’s perspective. J Gen Intern Med. 2001;16:750–4.PubMedCrossRefGoogle Scholar
  31. 31.
    Didden DG, Philbrick JT, Schorling JB. Anxiety and depression in an internal medicine residency continuity clinic: difficult diagnoses. Int J Psychol Med. 2001;31:155–67.CrossRefGoogle Scholar
  32. 32.
    Issacson JH, Fleming M, Kraus M, Kahn R, Mundt M. A national survey of training in substance use disorders in residency programs. J Stud Alcohol. 2000;61:912–5.Google Scholar
  33. 33.
    Kraus ML, Isaacson JH, Kahn R, Mundt MP, Manwell LB. Medical education about the care of addicted incarcerated persons: a national survey of residency programs. Substance Abuse. 2000;22:97–104.CrossRefGoogle Scholar
  34. 34.
    Hicks CM, Gonzalez R, Morton MT, Gibbons RV, Wigton RS, Anderson RJ. Procedural experience and comfort level in internal medicine trainees. J Gen Intern Med. 2000;15:716–22.PubMedCrossRefGoogle Scholar
  35. 35.
    Wickstrom GC, Kolar MM, Keyserling TC, et al. Confidence of graduating internal medicine residents to perform ambulatory procedures. J Gen Intern Med. 2000;15:361–5.PubMedCrossRefGoogle Scholar
  36. 36.
    Wickstrom GC, Kelley DK, Keyserling TC, et al. Confidence of academic general internists and family physicians to teach ambulatory procedures. J Gen Intern Med. 2000;15:353–60.PubMedCrossRefGoogle Scholar
  37. 37.
    Taragin BH, Feng L, Ruzal-Shapiro C. Online radiology appropriateness survey: results and conclusions from an academic internal medicine residency. Acad Radiol. 2003;10:781–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Canaris GJ, Flach SD, Tape TG, Stierwalt KM, Haggstrom DA, Wigton RS. Can internal medicine residents master microscopic urinalysis? Results of an evaluation and teaching intervention. Acad Med. 2003;78:525–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Watkins RS, Moran WP. The impact of targeted resident education and feedback on pap smear adequacy rates. J Gen Interen Med. 2004;19:545–8.CrossRefGoogle Scholar
  40. 40.
    Salerno SM, Alguire PC, Waxman HS. Competency in interpretation of 12-lead electrocardiograms: a summary and appraisal of published evidence. Ann Intern Med. 2003;138:751–60.PubMedGoogle Scholar
  41. 41.
    Rubin CD, Stieglitz H, Vicioso B, Kirk L. Development of geriatricsoriented faculty in general internal medicine. Annals Intern Med. 2003;139:615–20.Google Scholar
  42. 42.
    Mullan PB, Weissman DE, Ambuel B, von Gunten C. End-of-life care education in internal medicine residency programs: an interinstitutional study. J Palliative Med. 2002;5:487–96.CrossRefGoogle Scholar
  43. 43.
    Schwartz CE, Goulet JL, Gorski V, Selwyn PA. Medical residents’ perceptions of end-of-life care training in a large urban teaching hospital. J Palliative Med. 2003;6:37–44.CrossRefGoogle Scholar
  44. 44.
    Liao S, Amin A, Rucker L. An innovative, longitudinal program to teach residents about end-of-life care. Acad Med. 2004;79:752–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Weissman DE, Mullan PB, Ambuel B, von Gutten C. End-of-life curriculum reform: outcomes and impact in a follow-up study of internal medicine residency programs. J Palliative Med. 2002;5:497–506.CrossRefGoogle Scholar
  46. 46.
    Tierney WM, Dexter PR, Gramelspacher GP, Perkins AJ, Zhou XH, Wolinsky FD. The effect of discussions about advance directives on patients’ satisfaction with primary care. J Gen Intern Med. 2001;16:32–40.PubMedCrossRefGoogle Scholar
  47. 47.
    Orsetti KE, Frohna JG, Gruppen LD, Valle J. Impact of a veteran’s affairs continuity clinic on resident competencies in women’s health. J Gen Intern Med. 2003;18:419–22.PubMedCrossRefGoogle Scholar
  48. 48.
    Pursley HG, Kwolek DS, Griffith CH, Wilson JF. Women’s health issues and residents’ knowledge. J Kentucky Med Assoc. 2002;100:238–44.Google Scholar
  49. 49.
    Dixon JG, Bognar BA, Keyserling TC, et al. Teaching women’s health skills: confidence, attitudes and practice patterns of academic general physicians. J Gen Intern Med. 2003;18:411–8.PubMedCrossRefGoogle Scholar
  50. 50.
    McGarry KA, Clarke JG, Cyr MG, Landau C. Evaluating a lesbian and gay health care curriculum. Teach Learn Med. 2002;14:244–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Block JP, DeSalvo KB, Fisher WP. Are physicians equipped to address the obesity epidemic? Knowledge and attitudes of internal medicine residents. Preventive Med. 2003;36:669–75.CrossRefGoogle Scholar
  52. 52.
    Mincey BA, Parkulo MA. Antibiotic prescribing practices in a teaching clinic: comparison of resident and staff physicians. Southern Med J. 2001;94:365–9.PubMedGoogle Scholar
  53. 53.
    Denton GD, Smith J, Faust J, Holmboe E. Comparing the efficacy of staff versus housestaff instruction in an intervention to improve hypertension management. Acad Med. 2002;77:34–9.CrossRefGoogle Scholar
  54. 54.
    Houston TK, Connors RL, Cutler N, Nidiry MA. A primary care musculoskeletal clinic for residents. Successes and sustainability. J Gen Intern Med. 2004;19:524–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Vogelgesang SA, Karplus TM, Kreiter CD. An instructional program to facilitate teaching joint/soft tissue injection and aspiration. J Gen Intern Med. 2002;17:441–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Laidley TL, Braddock CH III, Fihn SD. Did I answer your question? Attending physicians’ recognition of residents’ perceived learning needs in ambulatory settings. J Gen Intern Med. 2000;15:46–50.PubMedCrossRefGoogle Scholar
  57. 57.
    Callahan M, Fein O, Battleman D. A practice profiling system for residents. Acad Med. 2002;77:34–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Embi PJ, Bowen JL, Singer E. A web-based curriculum to improve residents’ education in outpatient medicine. Acad Med. 2001;76:545.PubMedCrossRefGoogle Scholar
  59. 59.
    Spickard A III, Ryan SP, Muldowney JA III, Farnham L. Outpatient morning report: a new conference for internal medicine residency programs. J Gen Intern Med. 2000;15:822–4.PubMedCrossRefGoogle Scholar
  60. 60.
    Wenderoth S, Pelzman F, Demopoulos B. Ambulatory morning report: can it prepare residents for the American Board of Internal Medicine examination? J Gen Intern Med. 2002;17:207–9.PubMedCrossRefGoogle Scholar
  61. 61.
    Anderson RJ, Cyran E, Schilling L, et al. Outpatient case presentations in the conference room versus exam room: results from two randomized controlled trials. Am J Med. 2002;113:657–62.PubMedCrossRefGoogle Scholar
  62. 62.
    Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini CEX: a method for assessing clinical skills. Ann Intern Med. 2003;138:476–81.PubMedGoogle Scholar
  63. 63.
    Griffith CH III, Wilson JF, Langer S, Haist SA. Housestaff nonverbal communication skills and standardized patient satisfaction. J Gen Intern Med. 2003;18:170–4.PubMedCrossRefGoogle Scholar
  64. 64.
    Wilk AI, Jensen NM. Investigation of a brief teaching encounter using standardized patients: teaching residents alcohol screening and intervention. J Gen Intern Med. 2002;17:356–60.PubMedCrossRefGoogle Scholar
  65. 65.
    Varjavand N, Cohen DG, Novack DH. An assessment of residents’ abilities to detect and manage domestic violence. J Gen Intern Med. 2002;17:465–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Dresselhous TR, Peabody JW, Luck J, Bertenthal D. An evaluation of vignettes in predicting variation in the quality of preventive care. J Gen Intern Med. 2004;19:1013–8.CrossRefGoogle Scholar
  67. 67.
    Mazur EM, Cleary JP, Pols KB, et al. Collaboration between an internal medicine residency program and a federally qualified health center: Norwalk hospital and the Norwalk community health center. Acad Med. 2001;76:1159–64.PubMedCrossRefGoogle Scholar
  68. 68.
    Nelson HD, Cooney TG, Kroenke K, Friedman RH. Contributions of general internal medicine teaching units: a national survey. J Gen Intern Med. 2000;15:277–83.PubMedCrossRefGoogle Scholar
  69. 69.
    Randall DC, Strong J, Gibbons R. A longitudinal subspecialty experimence for internal medicine residents. Military Med. 2001;166:40–3.Google Scholar
  70. 70.
    Murden RA, Pintz EE. Housestaff-faculty ratios in ambulatory clinics and patient care and education. Acad Med. 2003;78:224.PubMedCrossRefGoogle Scholar
  71. 71.
    Young BL, Graham RP, Shipengrover J, James PA. Components of learning in ambulatory settings: a qualitative analysis. Acad Med. 1998;73(suppl):S60–3.PubMedCrossRefGoogle Scholar
  72. 72.
    Zayas LE, James PA, Shipengrover JA, Schwartz DG, Osborne JW, Graham RP. Exploring instructional quality indicators in ambulatory medical settings: an ethnographic approach. Fam Med. 1999;31:635–40.PubMedGoogle Scholar
  73. 73.
    Smith CS, Morris M, Hill W, et al. Cultural consensus analysis as a tool for clinic improvements. J Gen Intern Med. 2004;19:514–8.PubMedCrossRefGoogle Scholar
  74. 74.
    Holmboe ES, Huot S, Chung J, Norcini J, Hawkins RE. Construct validity of the miniclinical evaluation exercise (mini CEX). Acad Med. 2003;78:826–30.PubMedCrossRefGoogle Scholar
  75. 75.
    Durning SJ, Cation LJ, Markert RJ, Pangaro LN. Assessing the reliability and validity of the mini-clinical evaluation exercise for internal medicine residency training. Acad Med. 2002;77:900–4.PubMedCrossRefGoogle Scholar
  76. 76.
    Chen FM, Bauchner H, Burstin H. A call for outcomes research in medical education. Acad Med. 2004;79:955–60.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2005

Authors and Affiliations

  • Judith L. Bowen
    • 8
  • Stephen M. Salerno
    • 1
    • 2
  • John K. Chamberlain
    • 3
  • Elizabeth Eckstrom
    • 4
    • 5
  • Helen L. Chen
    • 6
  • Suzanne Brandenburg
    • 7
  1. 1.USUHS, Tripler Army Medical CenterHonoluluUSA
  2. 2.Internal Medicine ResidencyTripler Army Medical CenterHonoluluUSA
  3. 3.Department of Medicine and PediatricsUniversity of Rochester School of Medicine and DentistryRochesterUSA
  4. 4.Department of Internal MedicineLegacy Health SystemPortlandUSA
  5. 5.Department of MedicineOregon Health & Science UniversityPortlandUSA
  6. 6.University of California, San Francisco Veterans Affairs Medical CenterSan FranciscoUSA
  7. 7.Division of General Internal MedicineUniversity of Colorado Health Sciences CenterDenverUSA
  8. 8.Division of General Internal Medicine & Geriatrics, Department of MedicineOregon Health & Science UniversityPortland

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