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JGenInternMed.2005Dec20(12):11811187.

PMCID:PMC1490278

doi:10.1111/j.15251497.2005.0248.x

ChangingHabitsofPractice
TransformingInternalMedicineResidencyEducationinAmbulatorySettings
JudithLBowen,MD,1StephenMSalerno,MD,MPH,2,3JohnKChamberlain,MD,4ElizabethEckstrom,MD,MPH,5,6HelenL
Chen,MD,7andSuzanneBrandenburg,MD8
DivisionofGeneralInternalMedicine&Geriatrics,DepartmentofMedicine,OregonHealth&ScienceUniversity,Portland,OR,USA
USUHS,TriplerArmyMedicalCenter,Honolulu,HI,USA
InternalMedicineResidency,TriplerArmyMedicalCenter,Honolulu,HI,USA
DepartmentofMedicineandPediatrics,UniversityofRochesterSchoolofMedicineandDentistry,Rochester,NY,USA
DepartmentofInternalMedicine,LegacyHealthSystem,Portland,OR,USA
DepartmentofMedicine,OregonHealth&ScienceUniversity,Portland,OR,USA
UniversityofCalifornia,SanFranciscoVeteransAffairsMedicalCenter,SanFrancisco,CA,USA
DivisionofGeneralInternalMedicine,UniversityofColoradoHealthSciencesCenter,Denver,CO,USA
Theauthorshavenoconflictsofinteresttoreport
AddresscorrespondenceandrequestsforreprintstoDr.Bowen:DivisionofGeneralInternalMedicine&Geriatrics,DepartmentofMedicine,Oregon
Health&ScienceUniversity,3181SWSamJacksonParkRoad,L475,Portland,OR972393098(email:bowenj@ohsu.edu).
SeeeditorialbyHollyHumphrey.p.1189
Received2005Jul14Revised2005Jul26Accepted2005Jul26.
Copyright2005bytheSocietyofGeneralInternalMedicine

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract

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Purpose
Themajorityofhealthcare,bothforacuteandchronicconditions,isdeliveredintheambulatorysetting.Despite
repeatedproposalsforchange,themajorityofinternalmedicineresidencytrainingstilloccursintheinpatient
setting.Substantialchangesinambulatoryeducationareneededtocorrectthecurrentimbalance.Toassist
educatorsandpolicymakersinthisprocess,thispaperreviewstheliteratureonambulatoryeducationandmakes
recommendationsforchange.
Methods
TheauthorssearchedtheMedline,Psychlit,andERICdatabasesfrom2000to2004forstudiesthatfocused
specificallyoncurriculum,teaching,andevaluationofinternalmedicineresidentsintheambulatorysettingto
updatepreviousreviews.Studieshadtocontainprimarydataandwerereviewedformethodologicalrigorand
relevance.
Results
Fiftyfivestudiesmetcriteriaforreview.Thirtyfiveofthestudiesfocusedonspecificcurricularareasand11on
ambulatoryteachingmethods.Fiveinvolvedevaluatingperformanceand4focusedonstructuralissues.Nostudy
evaluatedtheoveralleffectivenessofambulatorytrainingorinvestigatedtheeffectsofcurrentresidentcontinuity
clinicmicrosystemsoneducation.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490278/

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Conclusion
Thisupdatedreviewcontinuestoidentifykeydeficienciesinambulatorytrainingcurriculumandfacultyskills.
Theauthorsmakeseveralrecommendations:(1)Maketrainingintheambulatorysettingapriority.(2)Address
systemsproblemsinpracticeenvironments.(3)Createlearningexperiencesappropriatetotheresident'slevelof
development.(4)Teachandevaluateintheexaminationroom.(5)Expandsubspecialtybasedtrainingtothe
ambulatorysetting.(6)Makefacultydevelopmentapriority.(7)Createandfundmultiinstitutionaleducational
researchconsortia.
Keywords:ambulatory,graduatemedicaleducation,curriculum,facultydevelopment,internalmedicine
Overthepast2decades,themajorityofhealthcaredeliveryhasshiftedtoambulatorysettings.Manyillnesses
previouslytreatedinthehospitalaresuccessfullymanagedinoutpatientpractices.Yet,internalmedicine
residencytrainingisstillprimarilyhospitalbasedwithcareofhospitalizedpatientstakingpriorityovertraining
inambulatorysettings.Forresidencyprogramaccreditation,only33%ofaresident'stotaleducationalexperience
mustbeintheoutpatientsetting.1Thusresidentsinfrequentlyhavetheopportunitytodeveloptherichand
rewardingcontinuityrelationshipswithpatientscharacteristicofambulatorypracticeortheskillsnecessaryto
performeffectivelyintheoutpatientsetting.2
Learningintheambulatorysettingisprimarilyexperiential.Althoughsupplementedbyconferencesand
independentstudy,continuityclinics,ambulatoryblockrotations,andsubspecialtyoutpatientpracticesarethe
primaryvenuesforthislearning.Analysisofatypicalfirstyearofresidencyrevealsasignificantdisparity
betweeninpatientandcontinuityclinictrainingexposure.Afirstyearresidentspendsaboutasmuchtimeinthe
hospitalduringthefirstmonthoftrainingashe/shewillspendinthecontinuityclinicsettingduringtheentire
firstyear(seeFig.1).Thisattenuatedexperiencemayresultinresidents'selfperceptionofincompetencein
clinicandleadtodissatisfactionbeforemasterycanbeachieved.38
FIGURE1
Comparisonofcumulativeexposure(days)betweencontinuityclinicand
hospitalbasedwardsoveratypicalfirstyearofinternalmedicine
residency.
Ambulatorypracticediffersfromthecareofhospitalizedpatientsinseveralfundamentalways:(1)Patientsare
typicallylessacutelyillandtheirproblemlistsarepopulatedwithchronicproblemsneedingperiodicreview.(2).
Thelevelofuncertaintyisgreater,fromdiagnosticaccuracytotherapeuticcompliance.Clinicaldecisionsmust
oftenbemadequicklyandsuccessmayonlybeseenwithlongitudinalvisits.(3)Patientcontactsaremarkedby
relativebrevityandirregularityatahecticpace,butcharacteristicallybecomecontinuousrelationshipsbetween
patientsanddoctorsovertime.
What,then,istheidealmodelforinternalmedicineresidenttrainingintheambulatorysettingthatprepares
residentsforindependentpractice?Whatistheevidenceforbesteducationalpracticesintheambulatorysetting?
AspartoftheSocietyofGeneralInternalMedicine's(SGIM)TaskForceforResidencyReform,wereviewedthe
publishedmedicalliteratureandconsultedwithexperiencedambulatorybasedphysicianeducatorsinaneffortto
addressthesequestions.

METHODS

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TheoreticalModelforLearninginAmbulatorySettings
Weusedanexperientiallearningmodeltoplacetheliteraturereviewinthecontextofatheoreticalmodel.Kolb
describesacontinuousprocessoflearningbasedonconcreteexperiencesfollowedbyactivereflectionthatleads
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tobuildingandrevisingconceptualapproachesandsubsequentapplicationofconceptstonewexperiences.9This
processisthecoreofclinicalbasededucationwhereexperiencewithpatientsfollowedbyactivereflectionand
feedbackleadstoimprovedperformance,competence,andconfidence.9,10Experienceisnecessaryforthe
developmentofdiagnosticexpertise1113andpracticeskillsuniquetoambulatorysettings.14
LiteratureSearch
WesearchedMedline,PsychLit,andERICdatabasesusingthefollowingsearchterms:ambulatorycareor
outpatientsoroutpatientclinicsorpreceptorship(ambulatorylocation)medicaleducationorteachingor
teachinghospitalsorlearningorcurriculum(medicaleducation)internship/residencyorhousestafforresidents
(residents)andinternalmedicine(discipline).Eachclusterofsearchtermswascombinedindependentlywiththe
otherclustersandlimitedtoEnglishlanguageandhumansubjects.WelimitedoursearchtoJanuary2000
throughDecember2004,relyingon2previouslypublishedreviewsoftheliteratureonambulatoryeducation
15,16
forstudiespublishedpriorto2000.Titlesandabstracts,whenavailable,werereviewed.Weincludedall
manuscriptsrelevanttointernalmedicineresidencytraininginambulatorysettingsthatstudiedorobservedsome
aspectoftrainingandpresentedresults.Publicationsthatdidnotincludeprimarydata,suchaseditorials,
programdescriptions,theoreticalmodels,oropinionswereexcluded.Reviewarticlesandanystudiesmore
relevanttoothersubgroupsoftheResidencyReforminitiative(e.g.,evidencebasedmedicinestudies)werealso
excluded.Atleast1authorreviewedeachoftheremainingstudiesindetail.Allauthorsdiscussedtheresultsof
thispreliminaryreviewandreachedconsensusinexcludinganyadditionalstudiesbasedonlackof
methodologicalrigororrelevancetoourquestions.Inpreparingthesynthesisreportedbelow,weobservedthis
existingliteratureregardingtraininginambulatorysettingstobeheterogeneousinscopeanddepth.Therefore,
somesectionsaredescribedingreaterdepthwheregreaterdetailinthereviewedliteraturewasavailable.Further,
innovativeprogramsthathavebeenundertakenbyseveralinstitutions,butnotyetreportedintheliteratureare
notdiscussedhere.Finally,ourpreliminaryconclusionsandrecommendationswerepresentedanddiscussedat
thenationalannualmeetingofSGIM,inevitablyinfluencingtheideaswepresenthere.

RESULTS

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Ninetythreestudiesmetourpreliminaryinclusioncriteria.Thirtyeightstudieswereexcludedafterreviewof
completemanuscripts,leaving55studies.Consistentwithpriorreviews,themajorityofstudieswerecompleted
insingleinstitutionsusingquasiexperimentaldesigns.Mostaddressedcurricularcontentgermanetothe
ambulatorysetting(35studies).Asmallernumberexploredteachingmethods(11),methodsofevaluating
performance(5),orthestructureofambulatoryeducation(4).Duetotheheterogeneousnatureofthesestudies,
resultscouldnotbecombined.

AmbulatoryMedicineCurricularContent

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Wegroupedstudiesinthiscategoryintoseveralcurriculartopicsareas:screeningandprevention(9studies),
behavioralmedicineandcommunication(8),diagnosticandproceduralskills(7),geriatricsandendoflifecare
(6),women'shealth(3),andothercurricularcontent(2).Overall,wefounddeficienciesinknowledgeand
performanceforbothresidentsandfacultyinavarietyofcurricularareas.

ScreeningandPrevention.

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Severalstudiesevaluatedresidentknowledge,attitudesandpracticesinhealthscreeningandpreventionusing
surveys,questionnaireresponsestoclinicalvignettes,chartreviews,andpatientexitinterviews.1725Residents'
knowledgeofscreeningguidelinesvariedwidelyacrossstudies.Residents'attitudesabouthealthscreening(e.g.,
papsmears)weregenerallymorefavorablethantheirattitudesaboutpreventivebehaviors(e.g.,physical
exercise).Ingeneral,residentslackedconfidenceincounselingskillsregardingprevention,andperceivedtheir
performancesinscreeningandpreventiontobebetterthanfoundonchartreview.Educationalprogramstended
toimproveperformance,althoughbenefitsweremodestforsomeactivities(e.g.,screeningfordomestic
21
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violence, )andfeedbackusingperformancereportcardsfailedtoresultinimprovementinscreeningorchronic
diseasemanagement.24Greaterintensityofambulatoryexperience,18chartprompts,andfacultyparticularly
dedicatedtopreventivecareimprovedresidentperformanceinotherstudies.20
Thus,theliteraturesuggestsroomforimprovementinresidents'confidenceandcompetenceindeliveringhealth
screeningandpreventiveservices.

BehavioralMedicineandCommunication.

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Severalstudiesaddressedteachingandlearningbehavioralmedicineandcommunicationskills.Resultsof2
nationalsurveysrevealedthatanaverageof99hoursperresidentisdevotedtobehavioralmedicineorpsychiatry
trainingininternalmedicineprogramsand79%ofthistrainingisexperiential.26,27Bothinternistsand
psychiatristsdidtheteaching.Themajorityofprogramdirectorsratedthistrainingasimportantandthought
moretrainingwasneeded.26
Fourstudiesaddressedthedoctorpatientrelationship.Onestudyshowedthatolderpatientshadlongervisits
withtheirresidentprovidersandweremoresatisfiedbutreceivedlesshealtheducationandcounseling,asked
fewerquestions,andwerelesslikelytobeaskedtomakebehaviorchanges.28Inanotherstudy,patient
satisfactionwithresidentpracticescomparedtofacultypracticesweremixed.29Twostudiesexamined
challengingdoctorpatientrelationships.Whenidentifiedbytheirresidentprovidersasproblematicor
difficult,patientsweremorelikelytohavelowsocialsupport,30anincreasednumberofpsychiatric
diagnoses,31andtodescribetheirresidentprovidersaslesscapable.30Anxietyanddepressionwerecommon
patientproblemsinthestudiedresidents'practices,butnotalwaysrecognizedanddiagnosed.
Twostudiessurveyedtrainingprogramsontheircurriculumrelatedtosubstanceabuse32andhealthcarefor
addicted,incarceratedpersons.33Themajorityofprogramstaughtaboutsubstanceabuseandviolenceasmaller
numberofferedclinicalexperienceswithprisoners.
Residents'continuitypracticesmayhaveahighprevalenceofpatientswithlowsocialsupportandpsychiatricco
morbiditiessuchasanxietyanddepression.Althoughmostprogramdirectorsagreedthatlearningbehavioral
medicinewasimportant,lackofsufficienttrainingmayimpairresidents'abilitiestocareforthepsychosocially
challengingpatientsintheirpractices.

DiagnosticandProceduralSkills.

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Wefound7studiesthatfocusedondiagnosticorproceduralskills.Twostudiessurveyedresidents'perceptionsof
theirpreparationtoperformcommonprocedures.34,35Confidencewashighestforinpatientprocedures.Time
andlackoffacultyproceduralexpertiseintheambulatorysettingwerecitedasbarriers.Althoughnumbersof
proceduresperformedweresmall,anotherstudyconfirmedfacultyexpertiseasabarrier,showingthatinternal
medicinefacultyconsistentlyperformedandsupervisedfewerprocedures,andfeltlessconfidentandplacedless
importanceonlearningambulatoryproceduresthanfamilypractitioners.36
Fourstudiesassessedresidentperformancewithdiagnostictests.Inthefirst,residents'abilitiestoselectthebest
radiologydiagnostictestinspecificcircumstancesrangedfrom13%to100%correct.37Inthesecondstudy,only
3%ofresidentphysicianspassedabaselinecognitivetestofurinalysisfindings.Improvementoccurredwith11
mentoringbutnotwithdidacticorcomputerbasedtraining.38Inathirdstudy,abriefmultifacetedintervention
improvedresidents'papsmearsampleadequacyratesby21%.39Inthefourthstudy,residentsdetected96%of
abnormalECGs,determined36%to80%ofcorrectdiagnoses,anddiscovered38%oftechnicalECG
abnormalities.40
Thisliteraturesuggeststhatresidentconfidencetoperformandfacultycompetencetoteachproceduresis
variable,potentiallyimpedingresidentpreparationforpractice.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490278/
GeriatricsandEndoflifeCare.

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GeriatricsandEndoflifeCare.

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Comparedtopriorreviews,ourreviewfoundanewemphasisonteachinggeriatricsandendoflifecare.Again,
facultycompetencewasvariable.Usingfocusgroupsandstructuredinterviewswithacademicleadersfrom49
medicalschools,Rubinfounddeficienciesingeriatricsteachingknowledgeandskills,suggestingasignificant
needforfacultydevelopmentingeriatrics.41Surveyresultsfromresidentsandfacultyat32internalmedicine
programsrevealeduniformrequirementsforsomedidacticsinendoflifecare,ethics,andpainmanagement,but
facultyknowledgeintheseareasvariedgreatly.42In1program,30%ofresidentshadnoexperiencewithdying
patientsintheircontinuitypracticesandperceivedthemajorityoftheirfacultytohavesuboptimalexpertisefor
teachinginthisarea.43Anotherprogramimplementedalongitudinalelectiveutilizingcommunitybasedhome
hospiceagenciesandfacultypatients,resultinginan8.2%improvementintestedknowledgeinendoflifecare,
aswellashighlevelsofresident,faculty,andpatientfamilysatisfaction.44Endoflifecurriculahavebeen
developed,implemented,andparticipantsatisfactionevaluatedwithpositiveresults,45includingincreased
patientsatisfactioncorrelatingwithhavingdiscussedadvancedirectiveswiththeirresidentphysicians.46
Residentcompetencies,however,werenotmeasured.
Aspopulationdemographicsshift,internalmedicineresidentsaremorelikelytoprovidecareforolderadults,
andwillfaceendoflifecaredecisionswiththeirpatients.Programdirectorsbelievethatgeriatricsandendof
lifecurriculaareimportant,butfacultyappearinadequatelypreparedtoteachthesetopics.

Women'sHealth.

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Threestudiesaddressedtraininginwomen'shealth.Residentcompetencyappearsinfluencedbycontinuityclinic
site,adequaciesofthecurriculum,andfacultyconfidenceinteachingwomen'shealth.In1study,residentswith
clinicattheVeteran'sAffairsmedicalcenterhadlowerknowledgeofwomen'shealthissuesandlesscomfort
performingproceduresthanresidentsattheUniversityorcommunityclinicsites.47Asurveyofresidentsin1
programrevealed41%ofresidentswithknowledgeshortfallsinwomen'shealth,butonly74%oftheseresidents
perceivingtheinadequacy.48Inanothersurvey,allfacultyfeltwomen'shealthskillswereimportant,butinternal
medicinefacultyweresubstantiallylessconfidentthanfamilymedicinefacultyregardingseveralwomen'shealth
skills.49
Thisliteraturesuggeststhatwomen'shealthcurricula,residentperformance,andfacultycompetencearehighly
variable,potentiallyleavingmanyresidentsillpreparedtoaddresstheuniqueneedsofwomenintheirfuture
practices.

OtherCurricularAreas.

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Followingparticipationinanelectiverotationongayandlesbianhealthatasingleinstitution,residentsreported
improvedpreparednessinaddressingthehealthneedsoftheirgayandlesbianpatients,butimprovedcomfort
withgayandlesbianpatientswasnotobserved.50Asurveyofresidents'knowledgeandattitudesregarding
obesitysuggeststhatinternalmedicineresidentsareillequippedtoaddressthisemergingepidemic.51

TeachingMethods

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Educatorsuseavarietyofteachingmethodstopromotelearninginambulatorysettings.Weidentified11studies.
Althoughcontentvaried,thisliteraturesupportsexperientiallearningthroughdirectpractice,rolemodelingand
consistentrelationshipsbetweenresidentsandteachers.
Facultyrolemodelingofantibioticprescribingpracticesappears,overtime,toinfluenceresidents'prescribing
practices,evenwhenthefaculty'shabitswerecharacterizedasinappropriate.52Inanotherstudy,faculty
outperformedresidentsasteachersofaguidelineconsistenthypertensionprotocol.53Assignmenttoa
communitybasedmusculoskeletalmedicineclinicimprovedresidents'opportunitytolearnandpracticejoint
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injections. Opportunitytopracticejointaspirationandinjectionskillsonmanikinswasasuperiorteaching
methodwhencomparedtolecturesaloneorcasebasedinstruction.55
Facultyandresidentsdonotalwaysagreeonthelearningagendaincontinuitypractices.Laidleyetal.56found
only40%agreementbetweenaresident'seducationalpriorityandfaculty'sperceivededucationalneed.Higher
agreementwasnotedwhenresidentfacultypairswerestableovertime,suggestingresidentcontinuitywith
preceptorsmayimprovethepreceptor'seffectivenessintargetingteaching.
Theeffectoffeedbackonpracticebehaviorsislessclear.Inasingleinstitutionstudy,almostallresidentsfound
patientfeedbackregardingcommunication,electronicmedicalrecordfeedbackondiseasemanagement,and
feedbackfromfacultyuseful,butonlyhalffeltthe3partprofileswouldinfluencetheirpracticestyles.57In
anotherstudy,feedbackdidnotimproveresidentperformance.24
Conferencescontinuetosupportexperientiallearning.Casebasedteachingisacommonmethodofinstruction,
includingusingtheInternettopostcasesandreadingmaterials.58Resultsfromanationalsurveyof404internal
medicinedepartmentsrevealsa24%prevalenceofanoutpatientmorningreporttypeconference,59although1
programusingambulatorymorningreport5timesweeklyaspartofablockrotationfailedtoshowimproved
outcomesontheABIMcertifyingexamination.60
Finally,1studysupportedpriorfindingsthatpatientscontinuetoexpresspreferenceforbedsidediscussionsof
theircases,althoughpatientsatisfactiondidnotdifferbylocationofcasediscussions.61Asmallminorityof
residentsfeltlossofautonomyandsomefeltawkward.
Experiencewithpatientsincludingdirectcare,andfacultyrolemodelingremaintheprimaryteachingmethodin
ambulatorysettings.Didacticandcasebasedfacultyorresidentleadconferencesarecommonbuttheimpacton
learningisunknown.Aswithpriorstudies,patientspreferexamroomteaching.

EvaluationofPerformance

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Weidentified5studiesusingdirectobservationmethodology.AstudyofthefeasibilityofusingtheminiClinical
EvaluationExercise(CEX)toevaluateinternalmedicineresidents'performancesinmultiplesettings,including
ambulatoryclinics,revealedhigherfidelityandlowercoststhanuseofstandardizedpatients.Aminimumoften
observationsperresidentwasrequiredtoproducereliableresultsinordertodiscriminatebetweenlevelsof
performance.62
Threestudiesusedstandardizedpatients(SPs)toevaluateresidents'performances.Onedemonstratedapositive
associationbetweenresidentnonverbalcommunicationskillsandpatientsatisfaction.63Anotherdocumented
improvedresidentperformancewithunannouncedSPs.64Anotherinstitutiondocumentedwidevariationsin
residentperformanceincludingmakingincorrectrecommendationstopatientsonadomesticviolenceobserved
structuredclinicalevaluation(OSCE).65Afourthstudysuggestedclinicalvignettesusingcomputerizedcase
scenariosmayofferanalternativetostandardizedpatientsinassessingqualityofcare.66
TheliteraturecontinuestosupporttheuseofminiCEXforevaluationintheambulatorysetting.Althoughresults
aremixedandcontentdependent,supportforuseofmoreexpensivemethodsofdirectobservationiscurrently
lacking.

ProgramStructure

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Communitybasedteachersandsubspecialtytrainedinternistscontinuetoplayasignificantroleasteachersin
theambulatorysetting.In1collaborationbetweenaninternalmedicineresidencyprogramandafederally
qualifiedhealthcenter,residentandpatientsatisfactionimproved,butthegrantdidnotoffsetthehospital's
financialinvestment.67Anationalsurveyofgeneralinternalmedicineteachingunitsshowedthatgeneral
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internistvolunteersoutsideoftheuniversityenvironmentdoasignificantportionofinternalmedicine
teaching.68
Onestudydescribeda3yearexperienceintegratingambulatorysubspecialtyeducationintocontinuityclinics.In
thespecialtyareaswherelargevolumesofresidents'patientswerereferred(andresidentsattendedtheclinics),
intrainingexaminationscoresimproved.Innonparticipatingspecialtyareas,intrainingexaminationscores
declined,althoughdifferencesinbothdirectionsweresmallandbaselinelearnerperformancewasnotreported.69
Evaluatingpreceptorresidentandpreceptorpatientcontacttime,andresidentchartingerrors,1studyshowedno
significantdifferencesinclinicalerrorsorpreceptorresidentcontacttimeat2differentpreceptorresidentratios
(1:3vs1:5to6).However,increaseddidacticandpreceptorpatientcontacttimewasnotedforthelower
preceptorresidentratio.Differencesinteachingeffectivenessorsatisfactionwerenotreported.70

DISCUSSION

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Althoughwecanlearnsomethingoftheprioritiesandconcernsofresidencyprogramsfromreviewingtrendsin
publishedstudies,thisreviewhighlights,forthemostpart,localratherthanglobalconcerns.Moststudiesare
completedatsingleinstitutions,atrendidentifiedfrompriorreviews.Further,theliteraturewereviewedis
repletewithneedsassessmentsidentifyingsignificantcurricularorinstructionaldeficienciesinmultiple
contentareasrelevanttoteachingandlearningintheambulatorysetting,butprovideslittleguidanceforhowto
respondtotheseshortcomings.Internalmedicineeducatorscontinuetocreateinnovativeprogramstoaddress
importanteducationalproblems,buttheheterogeneityofthepublishedstudies,andthelackofmethodological
rigorandmulticenterdesignssignificantlylimitsourabilitytodrawbroadconclusionsfromthisliterature.
Nationalsurveysdorevealthatprogramdirectorsvaluebehavioralmedicinetrainingbutfewhoursarededicated
tothistraining,andfacultylackskillsandknowledgeingeriatricsandendoflifecarethathamperstheir
teachingabilitiesintheseareas.Smallerstudiesraiseconcernsaboutoutpatientteachers'abilitiestoteach
ambulatoryproceduralskills.Althoughspecificrecommendationsforevaluationofskillsandcompetencyin
performingproceduresareoutsidethescopeofthisreview,thesefindingsmayhelpfocusfuturefaculty
developmentefforts.
Severalstudiesconsistentlyfoundthatresidentsoftenlackconfidenceandcompetenceinaddressingmany
commonambulatoryhealthissues.Oneexplanationmightbethatresidentssimplydonothaveenough
experienceintheambulatorysettingtomastertheseskills,ortodevelopexpertiseindeliveringsuchcare.While
programsarerequiredtoprovide33%oftraininginambulatorysettings,onlyapproximately13%oftherequired
33monthsofclinicaltrainingoccursinthecontinuitypracticesetting.Itisdifficulttodeveloppractice
competencewithsolittleexposure.
Shouldallinternalmedicineresidentshaveincreasedclinicaltraininginambulatorysettings?Somewouldargue
thatresidentsmightbenefitfromtrainingtrackstailoredtotheircareerplans,sothatresidentsboundforcareers
ashospitalistswouldfocusonhospitalbasedtraining.Reportingontrainingtrackdiscussionsisbeyondthe
scopeofthisreport.Wedobelieve,however,thatthecoreofinternalmedicinetrainingattheresidencylevel
shouldincludeamorerobustexposuretocontinuitypracticeregardlessoftheresident'sfuturecareerchoice.The
movetowardprovidingmoreprimaryandsubspecialtycareinoutpatientsettingsratherthaninpatientsettings
andshorterlengthsofstayinhospitalssuggestthatcontinuityclinicmaybeanincreasinglyimportantvenuefor
internalmedicinetraining.Thecallforimprovedskillsanddemonstratedcompetencyinsystemsbasedpractice
requiresanappreciationoftheentirehealthcaredeliverysystemasexperiencedfromthepatient'sperspective.
Residentsplanningcareersinprimarycare,hospitalmedicine,orsubspecialtypracticewillbenefitfrom
educationthatreflectsthecurrenthealthcareenvironment,includingmoreambulatorytraining.
Basedonourreviewoftheliteraturewithintheframeworkofexperientiallearningandconsultationwith
experiencedambulatorybasedphysicianeducators,wemakethefollowingrecommendations:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490278/
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MakeTrainingintheAmbulatorySettingaPriority

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Ifpatientcareexperiencewithreflectionisessentialforthedevelopmentofmasteryintheambulatorysetting,
trainingtimeincontinuityclinicsmustbeincreasedbeyond13%.Thiswillrequireasignificantculturalshiftin
internalmedicine.Theopportunitytofullyintegrateresidentsintotheirowncontinuitypracticesintheabsence
ofcompetinghospitalbasedservicedemandsisoftenabsent.Clearexpectations,rigorousevaluationand
feedback,andexperiencesuninterruptedbycoveragerequirementsinthehospitalwillbeneededtoincrease
residents'perceptionsthatambulatorybasedtrainingisvalued,valuable,andcanbemastered.Furtherresearch
shouldaddressthebenefitofimmersingresidentsintheircontinuityclinicssimilartotheirearlyhospitalward
rotations.Demonstratingvalueshouldalsoincludeappointingafacultymemberwithclearresponsibilityand
authorityforresidentambulatorytrainingandambulatoryfacultydevelopmentwhoreportstotheprogram
director,andincreasingtheResidencyReviewCommittee(RRC)continuityclinicrequirementtoatleast2
clinicsperweekduringnoncallmonths.

CreateLearningExperiencesandExpectationsAppropriatetotheResident's
LevelofDevelopment

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Giventheirlimitedexposureintheambulatorysetting,residentsoftenfacepatientswithcomplexmedicalissues
earlyininternshipthatarebeyondtheirlevelofdevelopment.Inthetimeconstrainedambulatoryenvironment,
theimpactofthisdevelopmentalmismatchonlearningisunknown.Anewmodelthattakesintoconsideration
thedevelopmentalleveloftheresidentwhilesupportingpatientcenteredcareshouldbestudied.Furtherresearch
shouldexploretherelationshipbetweenresidents'perceivedclinicalcompetenceinambulatorysettings,their
attitudestowardambulatorypractice,patientcomplexity,anddevelopmentalmodelsforsupervisionthatpromote
learningandselfefficacy.

StructureContinuityClinicsforSuccess

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Learningfromexperience,residentswillacquirehabitsofpracticefromthecaredeliverymodelinwhichthey
areimmersed.Thecurrentmedicalliteraturefailstoinformeducatorsofpracticemodelelementsthatinfluence
residents'practicehabits.Theoretically,ifresidentslearntopracticeinhighlyfunctionalenvironmentsthat
deliverhighquality,patientcenteredcare,theywillcarrythosehabitsofpracticeintotheirfutures.Thestructure,
function,andsharedvalueswithinthepracticesettinghavepreviouslybeenidentifiedasimportantfeaturesof
positivelearningenvironments.7173Possiblefeaturesoftheidealpracticeinclude:promotinglongterm
relationshipswithpatients,developingnormativedistributionsofpatientcomplexityandpsychosocialchallenge
inresidents'panels,creatinglongtermrelationshipswithone'ssupportstaff,delegatingpatientcare
responsibilitiestootherteammembers,designinghighlyfunctionalspace,developingefficientsystemsofcare
forchronicdiseasemanagement,andpromotingapatientcenteredworkethic.Theseidealpracticeswilllikely
includeinterdisciplinaryteamsthatsupportresidents'careoftheircomplexpatients,includingsocialworkers,
psychologistsorpsychiatrists,nurses,pharmacists,andothers.Ultimately,suchpracticeenvironmentsmaybe
positivesettingsforlearningabouthealthsystems,managementofchronicconditions,qualityimprovement,and
engenderresidentinvestmentinthesuccessofthepractice.

ExpandSubspecialtyBasedTrainingtotheAmbulatorySetting

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Theoutpatientclinicisnotsolelythedomainofthegeneralist.Althoughthepredominantmodelforlearning
subspecialtycontentareasofinternalmedicineisthehospitalbasedconsultservice,someprogramsassign
residentstosubspecialtyclinics,whichmaybeanideallocationforlearningtomanagemanychronicconditions.
Furthermore,manypatientsadmittedtothehospitalfromsubspecialtyclinicshaveknowndiagnosesand
articulatedmanagementplans.Increasingtrainingopportunitiesforresidentsinsubspecialtyoutpatientclinics
mayprovideresidentsincreasedexperienceinevaluatingundiagnosedsymptomsandacuteexacerbationsof
chronicdiseases.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490278/
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TeachandEvaluateintheExaminationRoom

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ThegrowingbodyofevidencethattheminiCEXisareliableandvalidmeasureofresidents'observed
performanceshouldaccelerateinclusionofthisevaluationmethodintothedailyactivitiesofteachingin
continuityclinics.74,75Patientshaveagainindicatedtheirdesirethatfacultyspendtimewiththematthebedside
(intheexaminationroom)duringteachingencounters.Makingexaminationroomteachingaregularhabitshould
increasethefidelityoftheevaluations,andmayimprovesatisfaction,optimizefacultyresidentratios,and
increasebillings.Providingevaluationandfeedbackonafocusedportionoftheresidentpatientencounterallows
integrationoftheminiCEXwithoutdisruptingpatientflow.

MakeFacultyDevelopmentaPriority

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Evidentinmanyofthestudiesisalackoffacultyexpertise(orconfidence)inteachingambulatorymedicine.
Improvingtheindependentpracticeabilitiesofinternalmedicineresidentswillrequireimprovedfacultyskills.
Departmentanddivisionchiefsshouldsupportprotectedtimeforfacultydevelopmentonaperiodicbasisto
sustainthiseffort.Teachingexcellenceshouldbemeasuredandvaluedasmuchasclinicalproductivity.Faculty
developmentshouldaddresscoreteachingskills,thecorecurricularcontentforinternalmedicine(includingbut
notlimitedtothedeficienciesidentifiedhere),andmentoringskills.

CreateandFundMultiInstitutionalEducationalResearchConsortia

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Whileimportant,thepredominanceoflocalneedsassessmentreportsinthecurrentliteraturereviewfailsto
advancethefieldofmedicaleducationinanysignificantway.Residents'continuitypracticescanserveas
researchlabsinaddressingimportanteducationalquestionsanddiscoveringbesteducationalpractices.More
rigorousresearchstudydesignsandastrongerlinkbetweeneducationalprocess,educationaloutcomes,and
patientoutcomesareneeded.76Studiesshouldbedesignedandconductedwithclearinterventionsthatcanbe
adaptedtomultipleinstitutions.
Inadditiontoincreasingthenumberofstudiespublishedinthemedicalliterature,multiplevenuesforsystematic
sharingofbestpractices(e.g.,workshopsatregionalandnationalmeetings,andWebbasedrepositoriesand
publications)areneeded.

LIMITATIONS

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Ourstudyhaslimitations.Althoughourintentionwastobecomprehensive,wemayhavefailedtoidentifyor
overlookedimportantcontributionstotheliterature.Therewerefewmethodologicallyrigorousstudiesacross
multipleinstitutionswithdetailedenoughmethodstoresultinwidespreadgeneralizability.Thus,someofour
recommendationsarebasedondiscussionswithexpertsandknowledgeoflearningtheories,andmaybelesswell
supportedbyempiricalevidenceuntilfurtherresearchisconducted.Whilestudiesreportedheresuggeststrong
interestintheareasofscreeningandprevention,behavioralmedicineandcommunication,proceduralskills,and
endoflifecare,manymoreunpublishedcurricularadvanceslikelyexistandknowledgeoftheseadvancescould
haveshapedourrecommendationsdifferently.Finally,thisliteraturereviewdoesnothingtohelpdeterminehow
besttoimplementthesesuggestions.Eachresidencyprogramhasitsownstrengthsandchallenges.Financial
pressuresmaylimitavailableresources,includingfacultytimeorclinicalspace.Manyfacultyfacesignificant
clinicalproductivitypressuresrewardsforeducationalinnovationandexcellencemaybelacking.Facultymay
notperceivetheneedforselfimprovement.Educatorsshouldinterpretourrecommendationsbasedonindividual
needs.
Fromcommunitybasedteacherstoacademicleaders,manyinternistshavedevotedtheirlivestoimproving
teachingandlearninginambulatorysettings.Thetheorybasedrecommendationssuggestedhereneedscientific
validationinoutpatientteachingsettingswithafocusonoutcomebasedassessments,followedbyanongoing
nationaldialoguethatleadstomeaningfultransformationofambulatorytrainingininternalmedicinethatwill
resultinimprovedcompetenceandconfidencefordeliveringhighquality,patientcenteredcare.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490278/
DISCLAIMER

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DISCLAIMER

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Theopinionsorassertionscontainedhereinaretheprivateviewsoftheauthorsandarenottobeconstruedas
officialorasreflectingthoseoftheDepartmentoftheArmyortheDepartmentofDefense.

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ArticlesfromJournalofGeneralInternalMedicineareprovidedherecourtesyofSocietyofGeneralInternalMedicine

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490278/

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