Ambulatory Training Since Duty Hour Regulations: A Survey of Program Directors
Article Outline
Ambulatory care is an important part of clinical practice for most internists, regardless of whether they pursued subspecialty training. Consequently, the Accreditation Council for Graduate Medical Education requires that internal medicine residents spend at least 33% of their clinical time in the ambulatory setting. Despite this requirement, research suggests that internal medicine residencies do not do a good job of preparing their learners for ambulatory practice.1, 2, 3, 4 There is considerable interest in improving the quality of ambulatory training in internal medicine residency programs. A reasonable first step would be to examine current practice: the educational and clinical activities currently used to develop resident skills in ambulatory medicine.
Despite guidance regarding the body of knowledge that internists should master in ambulatory settings,5, 6 there is little current information regarding how residency programs across the United States help residents to do so. Although many individual training programs have described specific innovative educational activities focused on ambulatory care,7 few data exist about how widely these innovations have been adopted. Several articles have discussed the use of newer technologies to help medicine residents learn outpatient medicine,7, 8, 9, 10, 11, 12 but it is unclear how often these technologies are used across residency programs. Moreover, much of this information was generated before Accreditation Council for Graduate Medical Education-mandated changes in resident duty hour regulations went into effect July 1, 2003. These changes have forced many internal medicine residency programs to restructure how they provide residents with clinical experiences in ambulatory settings.13
Therefore, we surveyed the 381 residency program directors who are members of the Association of Program Directors in Internal Medicine regarding the ambulatory clinical experience of the average resident in their program. We asked how the knowledge base relevant to ambulatory practice was conveyed, with particular attention to instructional methods and the use of recent innovations, as well as whether and how Accreditation Council for Graduate Medical Education-mandated changes in duty hours have affected their residents' ambulatory clinical experience.
Materials and Methods
We drafted questions to address the targeted topics and then asked faculty knowledgeable about local residency programs to comment on how feasible it was to answer them. We forwarded revised questions to the Association of Program Directors in Internal Medicine Survey Committee, which provided additional feedback. The committee incorporated these questions into its yearly web-based internal medicine residency program director survey, administered by the Mayo Clinic Survey Research Center. In November 2006, the Survey Research Center sent the survey, accessed by a link in an e-mail, to all program director members in the Association of Program Directors in Internal Medicine. The center sent monthly reminders to nonresponders until February 2007. In March 2007, the Association of Program Directors in Internal Medicine Survey Task Force made telephone calls to nonresponders requesting participation. The Center closed the survey in mid-April 2007, after receiving 236 useable responses to the survey, a 62% response rate. Responders were geographically similar to nonresponders but had slightly higher American Board of Internal Medicine pass rates (92.9% vs 90.8%, P = .004). A total of 208 program directors (88%) provided usable answers to questions about where ambulatory clinical time was spent, which forms the basis of this report. We analyzed the data using Stata 8 (Stata Corporation, College Station, Tex).
Results
The mean total percent of time residents spend in the ambulatory setting is 46.9% (standard deviation, 25.5%). This proportion increases over the course of residency, from 35.7% for first-year residents (postgraduate year 1), to 49.0% for second-year residents (postgraduate year 2), to 55.9% for third-year residents (postgraduate year 3). Although all residents have a personal continuity clinic as required by Accreditation Council for Graduate Medical Education standards, the majority of ambulatory clinical experience occurs in other settings (Table 1). The largest contribution to the residencies' total ambulatory clinical experience comes during subspecialty rotations that include both inpatient and outpatient experiences. Ambulatory block rotations (including both non-continuity general medicine blocks and ambulatory blocks in 1 or several subspecialties) and the weekly continuity clinic experience contribute almost equally to the residencies' total ambulatory time. Emergency department and urgent care rotations also are commonly used to fulfill ambulatory requirements.
Table 1. Types of Ambulatory Experiences Used by Programs by Year of Traininga
| Postgraduate Year 1 (n  =207b) | Postgraduate Year 2 (n =208) | Postgraduate Year 3 (n =208) | ||||
|---|---|---|---|---|---|---|
| N (%) Programs Having Rotation | Mean % of R1 Year Spent in Rotation | N (%) Programs Having Rotation | Mean % of R2 Year Spent in Rotation | N (%) Programs Having Rotation | Mean % of R3 Year Spent in Rotation | |
| Resident's own continuity clinic | 207(100) | 11.5% | 208(100) | 13.0% | 208(100) | 13.4% |
| Other continuity or longitudinal clinic | 76(36.7) | 2.0% | 85(40.9) | 2.6% | 85(40.9) | 3.0% |
| Emergency medicine | 77(37.2) | 6.4% | 114(54.8) | 3.8% | 101(48.6) | 4.3% |
| Urgent care | 68(32.8) | 1.2% | 73(35.1) | 1.2% | 72(34.6) | 1.3% |
| Noncontinuity general medicine block | 88(42.5) | 3.1% | 100(48.1) | 4.3% | 115(55.3) | 5.3% |
| Other ambulatory block (eg, dermatology, otolaryngology, mixed specialty block) | 117(56.5) | 4.7% | 140(67.3) | 8.7% | 159(76.4) | 9.7% |
| Subspecialty rotation with both inpatient and outpatient experiences | 132(63.8) | 6.4% | 175(84.1) | 14.6% | 174(83.6) | 18.1% |
| Other | 14(6.8) | 0.5% | 16(7.7) | 0.7% | 18(8.6) | 0.9% |
| Total % ambulatory time | 35.7% | 49.0% | 55.9% | |||
aSurvey question: “Please indicate the percentage (%) of total time devoted to the following areas for each year of training (categorical residents only). This information typically is included on forms your program completes for the Residency Review Committee. Examples: ½ day per week continuity clinic = 3.33% per year (10% total for 3 years), 1-mo emergency block in R1 year = 3%, 2-mo ambulatory block in R3 year = 6%, 1-mo subspecialty rotation with ≥ 75% time in ambulatory setting = 3%, 1-mo subspecialty rotation with 25% to 75% ambulatory time = 1.5%, 1-mo subspecialty rotation with <25% ambulatory time = 0%.” |
bOne program reported ambulatory experiences for the R2 and R3 years, but not for the R1 year, thus the different N values across the 3 years. |
All program directors reported using conferences to help residents learn core ambulatory topics (Table 2). Most use noon conferences, but other types of conferences are common. Approximately 20% provide additional written independent study materials, which include internally developed reading lists and syllabi, ambulatory curricula developed and made available by other internal medicine residency programs (Yale14 or Johns Hopkins15), the American College of Physicians' Medical Knowledge Self-Assessment Program,16 and a variety of other materials.
Table 2. Interventions to Help Residents Learn Core Ambulatory Topics, n = 236
| Interventions | Percentage (%) of Programs |
|---|---|
| Noon conferences | 88.1 |
| Pre-continuity clinic conferences | 58.9 |
| Ambulatory morning reports | 48.3 |
| Required online self-study curriculum | 39.0 |
| Protected lecture time (eg, academic half-day) | 28.4 |
| Other independent study materials | 19.9 |
| Other intervention(s) | 6.4 |
Many programs have adopted technologic approaches to enhance the residency experience. More than one third of programs have a required online curriculum for core ambulatory topics (Table 2). Most also report that residents have access to online clinical references to facilitate learning within the outpatient setting (90.7%). These resources almost always include UpToDate online (97%)17 and 1 or more library databases (85.5%). Some program directors (15.5%) report using web-based clinic question logs, and many (23.3%) provide their residents with personal digital assistants that usually include the pharmacy database Epocrates.18 More than one third of program directors report that all residents in their program use an electronic health record in continuity clinic, although another one third report that no residents use an electronic health record in continuity clinic.
A total of 125 (53%) of the program directors state that the enforcement of duty hour regulations led to a redesign or directly affected ambulatory education. More than one third canceled post-call continuity clinics. Other changes are listed in Table 3. Independent changes forced by duty hour regulations, many program directors report the implementation of innovative curriculum and unique clinical experiences to improve ambulatory education for their residents. Specific innovations are listed in Table 4.
Table 3. Changes Made to Ambulatory Education Because of Duty Hour Regulations, n = 125
| Changes Implemented | Percentage (%) of Programs |
|---|---|
| Postcall continuity clinics canceled | 70.4 |
| Increase in number of continuity clinics per week | 7.2 |
| Ambulatory blocks converted to night floats | 12.0 |
| Ambulatory blocks converted to ward months | 6.4 |
| Other continuity clinic redesign | 28 |
| Other ambulatory block redesign | 12.8 |
Table 4. Innovative Curriculum or Unique Clinical Experiences Implemented by Programs to Improve Ambulatory Education
| Innovative Curriculum/ Clinical Experiences | Description |
|---|---|
| Continuity clinic | Group-based practice system (residents in teams) (4), manager model (resident as teachers), ambulatory apprenticeships (postgraduate year 1 ambulatory block with mentor) |
| Ambulatory block rotations | Block expanded to include more unique experiences (eg, heart failure clinic, treadmills, preoperative clinic, outpatient procedures), 6-wk non-medicine outpatient rotation (eg, gynecology, orthopedics), incorporated variety of clinics: sports medicine, adolescent medicine, sexually transmitted disease clinic, nursing home, multispecialties block, dermatologist hired to teach |
| Special rotations or electives | Underserved ambulatory rotation, women's health elective, hospital administration elective, sleep medicine elective, bio-psychosocial mini-rotation, geriatric rotation (hospice/palliative care/ethics), musculoskeletal rotation (rheumatology, orthopedics, rehabilitation, physical/occupational therapy), substance abuse rotation, private practice rotation, 6-wk non-medicine ambulatory block, continuity clinic elective, teaching skills rotation for postgraduate year 3 |
| Didactics and conferences | Pre-clinic conferences improved on (4), pre-clinic conferences led by residents (2), designated ambulatory conferences led by residents (2), pre-clinic conferences 2.5-y rotating curriculum, ambulatory morning report, monthly ambulatory morbidity and mortality conference, ambulatory journal clubs, medical errors disclosure conference |
| Workshops/seminars | Communication/interviewing skills seminars (3), evidence-based medicine course, ½ day seminar per week during ambulatory block, ambulatory procedural skills course, 2-wk systems-based practice course, professionalism seminar |
| Projects | Quality improvement and/or practice-based learning and improvement projects (19) |
| Ambulatory curriculum | Web-based ambulatory curriculum (4), Hopkins ambulatory curriculum (4), chronic disease management curriculum (4), American Board of Internal Medicine Practice Improvement Modules (3), Challenger software, Tuft's managed care curriculum, Yale curriculum, web-based behavioral medicine curriculum, cultural sensitivity curriculum, evidence-based medicine curriculum, health screening curriculum |
| Evaluation methods | Ambulatory clinical report cards (chart audit) (3), web-based knowledge tests (3), continuity clinic patient satisfaction questionnaires (2), objective structured clinical examination (2), videotaped encounter (2), standardized patients, learning objective/procedural objective checklist cards completed by faculty, end-of-rotation knowledge tests based on conference material |
| Other experiences | Home visits (4), nursing home visits, role playing, community outreach program |
Discussion
We believe that this survey of a national sample of residency program directors is the first description of how ambulatory practice knowledge and skills are taught to internal medicine residents across the range of residency programs. This realization is surprising because there have been many calls for improvements to ambulatory training and many descriptions of innovative approaches.
Most program directors do not have difficulty meeting the 33% required clinical time in ambulatory practice; indeed, most programs report that the average resident far exceeds that goal, particularly in the second and third years. Although many educators think that residents' continuity clinics should be a priority, few programs exceed the minimum requirement of 1 half-day continuity clinic per week. Most programs fill the remainder of their residents' ambulatory clinical experiences with mixed inpatient–outpatient subspecialty rotations, ambulatory blocks, and emergency department rotations.
With the advent of the latest version of the Accreditation Council for Graduate Medical Education Program Requirements for Resident Education in Internal Medicine, effective July 1, 2009, these proportions will likely shift.19 Only 2 weeks of emergency medicine experience will count toward the total ambulatory time. Residents will have to complete 130 continuity clinics during a 30-month span of their residency training, which for some will mean an increase in continuity clinics, given that multiple exceptions had been made for past mandated “weekly” continuity clinics for vacation time, night float rotations, and critical care experiences.
Our findings suggest that ambulatory training approaches change rapidly. Almost all programs now use computers for at least part of their educational program. Approximately one half report they have recently or are currently implementing innovations in curriculum, organization, or evaluation methods. Although many resident continuity clinics do not have an electronic health record, the proportion that do is substantially higher than the 17% of primary care physicians who said they had even a basic electronic health record in a recent national survey.20 Electronic health records play an even more important role in the new Accreditation Council for Graduate Medical Education program requirements, which mandate that programs provide access to an electronic health records or at least “demonstrate an institutional commitment to its development and progress towards its implementation.”19 The requirements go on to require that continuity clinics “must include evaluation of performance data for each resident's continuity panel … [and] guidance for developing a data-based action plan … .” This kind of ambulatory performance improvement curriculum will often be facilitated by an electronic health record.
A striking feature of the survey responses is their diversity. In addition to the large number of program directors who report curricular innovations, there was wide variation in the ambulatory clinical experience of residents in different programs. Similarly, there are divergent approaches to delivering ambulatory didactic content. This range may be due to the paucity of data regarding which resident experiences are most useful for developing an internist who is competent in the ambulatory setting. This lack of data stems at least in part from the lack of agreed on measures of competence.
The enforcement of duty hour regulations has forced other changes that may challenge efforts to improve the quality of ambulatory training. More than one half of program directors state that duty hour regulations led to a redesign or directly affected their ambulatory education, most commonly cancellation of post-call continuity clinics. Although research has shown patient satisfaction to be reduced when the resident is post-call,21 this change further decreases time in continuity clinic. Our survey design did not permit us to determine whether programs were taking other steps to increase continuity clinic time, but only 8 program directors mentioned increasing the number of continuity clinics per week as a response to duty hour regulations, and none mentioned such a change as an innovation. Other responses to duty hour regulations (7 programs converted ambulatory blocks to ward months, and 13 programs converted ambulatory blocks to night float months) also will tend to decrease ambulatory exposure. Our findings are consistent with a previous study demonstrating that 36% of programs increased the hospital responsibilities of residents on outpatient rotations after the Accreditation Council for Graduate Medical Education duty hour regulations were instituted.22
These results cause concern in light of possible further decreases in resident duty hours, as recommended by the Institute of Medicine in December 2008.23 Our data suggest that many residencies responded to previous duty hour regulations by diminishing ambulatory experiences in favor of maintaining hospital services. Indeed, hospitals might lose their interest in supporting residencies if they cannot ensure that their service needs are met, particularly as the costs related to a hospitalist program approach the costs of a residency and as hospitalists become more numerous.
Limitations
Although we believe our survey is the most complete description of ambulatory training in internal medicine that is currently available, it does have limitations. First, many programs did not respond, and we were not able to determine whether the programs that responded are representative. Programs that are proud of recent innovations or have concerns about the impact of duty hour regulations might have been more likely to respond. Furthermore, weaker programs with less dedicated time for program management may have less time available to complete a survey. However, our response rate is similar to prior iterations of the Association of Program Directors in Internal Medicine's annual survey, which did not include questions on ambulatory training. Second, we have no independent confirmation that the training experiences are really as described. Even in an anonymous survey, program directors may think they should present their program in a favorable light. For example, we do not have an independent survey of residents that would confirm that 33% of clinical time is really spent in the ambulatory setting. Finally, the survey technique does not allow us to explore the reasons behind innovations or whether their implementation is successful.
Conclusions
Regardless, this survey should provide individuals interested in internal medicine ambulatory training with a sense of how it is typically done today, as well as a sense of which innovations are being adopted. In today's academic environment, programs face many challenges; however, the importance of ambulatory education cannot be forgotten. Our findings that duty hour regulations might have forced changes that limit the quantity of continuity clinic experience should be of concern to those who believe that the continuity clinic experience is particularly important. Moreover, these changes also may have decreased ambulatory time overall. We believe that studies similar to our own should be performed at intervals to track changes in ambulatory training approaches. In addition, focused studies, perhaps involving a selected subset of programs, will be needed to better understand trends identified by this and subsequent surveys.
Acknowledgments
We gratefully acknowledge the efforts of the Mayo Clinic Survey Research Center for assistance with survey design and data collection. We also thank Eric S. Holmboe, MD, and Lisa M. Bellini, MD, for helpful comments and advice regarding early drafts of the questionnaire.
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Funding: None.
Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this manuscript.
Authorship: All authors had access to the data and played a role in writing this manuscript.
PII: S0002-9343(09)00716-5
doi:10.1016/j.amjmed.2009.07.015
© 2010 The Association of Professors of Medicine. All rights reserved.
