Perspectives Viewpoints
- •Communities of practice are groups of people who share similar goals and interests and interact regularly.
- •Communities of practice have been effective in managing knowledge and improving performance across a wide range of settings.
- •Educational Innovations Project participants developed a close network of relationships, forming a successful and productive community of practice.
- •Professional organizations and accrediting bodies could consider this example as they seek to accelerate and sustain innovation.
The Education Innovations Project—A Community of Practice
In 2012, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Next Accreditation System (NAS) to free high-performing programs from meeting detailed requirements, enabling such programs to innovate.
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Although ACGME has taken this flexible approach towards accreditation, NAS does not describe optimal ways to innovate or manage new ideas. Importantly, 8 years before launching NAS, the Residency Review Committee for Internal Medicine (RRC-IM) laid out goals for a demonstration program called the Educational Innovations Project (EIP) that presaged many NAS attributes.Accreditation Council for Graduate Medical Education. Categorization of common program requirements. Available at: http://www.acgme-nas.org/ccpr.html. Accessed March 17, 2013.
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As EIP matured, its members developed a close network of relationships, forming a successful community of practice (CoP). In this article, we describe our CoP and suggest it as an example that professional organizations and accrediting bodies could consider as they seek to accelerate and sustain innovation.According to cognitive anthropologist Etienne Wenger, a CoP forms when a “group of people engage in a process of collective learning in a shared domain of human endeavor.”
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CoPs have been effective in managing knowledge and improving performance across a wide range of settings, including business, government, health care, and education.Wenger E. Communities of practice: a brief introduction. Available at: http://www.ewenger.com/theory/. Accessed March 17, 2013.
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, 5
, 6
CoPs can evolve naturally, as in the case of impressionist painters of the 19th century, or more deliberately, as in the case of EIP. Not everything called a community is a CoP.3
Large groups, such as ACGME or the Association of Program Directors in Internal Medicine (APDIM), are communities but not CoPs. Nor is a CoP simply a network of connections as one might find on a list server within an organization. Instead, members of a CoP such as EIP build relationships to learn from each other, share tacit knowledge, and develop resources that lead to improvement.Wenger E. Communities of practice: a brief introduction. Available at: http://www.ewenger.com/theory/. Accessed March 17, 2013.
3
, Wenger E. Communities of practice: a brief introduction. Available at: http://www.ewenger.com/theory/. Accessed March 17, 2013.
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The broad initial objectives of EIP were to create innovations that combined high-quality patient-centered care with competency-based education, develop educational and evaluative tools that could be disseminated and utilized broadly, and construct training models that better serve patients and the professional needs and career goals of residents.
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The RRC-IM selection criteria for EIP were:Accreditation Council for Graduate Medical Education. Educational Innovations Project. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/140_EIP_PR205.pdf. Accessed October 7, 2013.
- 1.Evidence of institutional commitment (EIP was unfunded).
- 2.Two previous accreditation cycles with a total of at least 8 years cycle length.
- 3.A current rolling American Board of Internal Medicine Certification Examination program pass rate of >80%.
- 4.A program director or associate program director that had been in place for at least 4 years.
- 5.An agreement to submit an annual program information form (shorter than the standard site-visit-associated form) as a yearly report of educational and patient care outcomes.
- 6.A willingness to disseminate innovations at the spring APDIM meeting and one additional national educational meeting each year (EIP meetings occurred in conjunction with spring and fall APDIM meetings).
In return for meeting these requirements, EIP participants were released from most of the prescriptive ACGME program requirements, excluding duty hours and patient volume caps, and were provided a 10-year accreditation cycle in which to innovate. Programs submitted annual program information files, and RRC-IM could remove programs from EIP for lack of objective evidence in enhancing patient care or education.
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In the first round of the application process, 123 programs were eligible to participate, 73 submitted letters of intent, and 17 programs were selected.Accreditation Council for Graduate Medical Education. Educational Innovations Project. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/140_EIP_PR205.pdf. Accessed October 7, 2013.
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In the second year, 4 more programs were chosen and then entry into EIP was closed. The 21 programs reflected the wide range of diversity across internal medicine residencies and included community and university programs, large and small programs, and primary care-based and prespecialty training programs (Table 1).Table 1Listing of EIP Programs
| EIP Programs Accepted in Initial Year | Type of Program |
| Abington Hospital, Philadelphia, PA | Community |
| Aurora Health, Milwaukee, WI | Community |
| Banner Good Samaritan, Phoenix, AZ | Community |
| Baystate Medical Center, Worcester, MA | Community |
| Henry Ford Hospital, Detroit, MI | Community |
| Long Island Jewish, Long Island, NY | Community |
| Scripps Mercy Hospital, San Diego, CA | Community |
| Summa Health System/Northeast Ohio University College of Medicine, Akron, OH | Community |
| Hennepin County Medical Center, Minneapolis, MN | Municipal |
| Beth Israel Deaconess, Boston, MA | University |
| Duke University, Durham, NC | University |
| Mayo Clinic, Rochester, MN | University |
| Ohio State University, Columbus, OH | University |
| Southern Illinois University, Springfield, IL | University |
| University of Cincinnati, Cincinnati, OH | University |
| University of Wisconsin Madison, WI | University |
| Westchester New York Medical Center, Westchester, NY | University |
| EIP Programs Accepted in Second Year | |
| Indiana School of Medicine, Indianapolis, IN | University |
| St. Barnabas Medical Center, Livingston, NJ | Community |
| University of Pittsburgh, Pittsburgh, PA | University |
| University of California San Francisco, San Francisco, CA | University |
EIP = Educational Innovations Project.
At the first national EIP meeting in 2006, each program was given 7 minutes to present innovations. At this early stage, none of the programs had collaborated with any other, but perhaps as a result of addressing common themes encountered in training residents, the presentations grouped among several primary content areas (Table 2). With common goals to address similar issues, the group began solving problems together, sharing best practices, and developing skills to improve resident training experiences.
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A CoP was born.Table 2Initial Common Innovation Themes of the EIP
| Focus | Percent of Total Projects (n) |
|---|---|
| Inpatient education | 24% (17) |
| Ambulatory education | 18% (13) |
| Handoffs/transitions | 17% (12) |
| Milestone-based evaluations | 11% (8) |
| Improve learning | 7% (5) |
| Teamwork training | 6% (4) |
| Medical humanities | 4% (3) |
| Advising residents | 4% (3) |
EIP = Educational Innovations Project.
Wenger describes 7 principles that organizations such as residency programs and accrediting bodies could use to cultivate CoPs (Table 3).
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Table 3Community of Practice Activities (adapted from Wenger)
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Wenger E. Communities of practice: a brief introduction. Available at: http://www.ewenger.com/theory/. Accessed March 17, 2013.
| Example Community of Practice Activities | EIP Examples |
|---|---|
| Problem solving | De-linking inpatient and ambulatory care Improving transitions of care Creating 16-hour duty shifts See also Table 2 |
| Requests for information | Sharing ideas between programs Reviewing one another's programs Using an electronic social networking site |
| Coordination and synergy | Receiving RRC-IM support Adopting national EIP coordinator |
| Discussing developments | Meeting semi-annually Convening frequent conference calls |
| Documentation projects | Publishing papers Collaborating in workshops Organizing yearly poster sessions |
| Visits | Holding ad hoc retreats Arranging interprogram site visits |
| Mapping knowledge and identifying gaps | Assessing ambulatory care milestones (Essentials of Ambulatory Care Study) Measuring ambulatory clinic structure affects patient care and learner satisfaction (Continuity Clinic Study) Assessing inpatient discharge milestones (initial project of the Educational Research Outcomes Collaborative–Internal Medicine—EROC-IM) |
EIP = Educational Innovations Project; RRC-IM = Residency Review Committee for Internal Medicine.
Principle 1: Design for Evolution
The purpose of CoP design is not to impose structure to accomplish a prespecified outcome, but instead, to develop more lifelong learning than “reading for the test.” CoPs develop a sense that Wenger calls “aliveness” when a community finds its own internal direction, character, and energy.
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EIP became “alive” soon after the initial RRC-IM-sponsored meeting when regional EIP leaders convened ad hoc meetings of their own accord (without RRC-IM presence) in the Northwest, Midwest, and Northeast. Programs voluntarily committed resources to produce and attend these meetings. Participants vigorously debated differing approaches to forming teams, measuring and improving outcomes, and defining success. A sense of group self-direction developed, guided by EIP member experience and the needs of the community. As EIP matured over time, this sense of autonomy led the group to identify early issues such as improving ambulatory education and creating 16-hour shifts, and later, to developing entrustable professional activities and milestones for assessment and reporting.Principle 2: Open Dialogue between Inside and Outside Perspectives
Our CoP design required an insider's perspective but also benefited from outside perspectives to see broader possibilities.
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Once EIP formed, there was an initial wariness about RRC-IM members and staff attending the semi-annual meetings. It was unclear what role RRC-IM should have in supporting and overseeing EIP, so early conversations were guarded in their presence. Fortunately, EIP participants engaged RRC-IM to express concern over “being watched.” Although this interaction could have been antagonistic, everyone involved reflected on the importance of setting clear expectations to help innovation move forward. The RRC-IM representatives clarified that their goal was to support the work of EIP and leverage success across APDIM and ACGME. As a result, RRC-IM became a member of the CoP, encouraging innovation and supporting outcomes, rather than a force to be feared.Principle 3: Invite Different Levels of Participation
CoPs often have 3 levels of participation.
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The first is a core group of people who assume leadership positions, identify projects for the group, and set the agenda for learning. The second is the active group who attend meetings and participate but not with the intensity of the first group. The third group is less vocal, keeps to the sidelines, and watches the core and active members interact. Soon after EIP formed, a core group of members created a leadership triumvirate of chair, chair-elect, and past chair. This group was highly active, interfacing with ACGME and RRC-IM, and leading the twice-yearly meetings. Most EIP members participated in these meetings, but some participants were clearly more active than others. However, as Wenger has noted, the people on the “sidelines” were not as passive as they seemed. They generated their own insights, brought these back to their home institutions, and often collaborated offline with other EIP members. An effective CoP allows for contributions at all 3 levels, depending on the needs of community members. Per Wenger, “rather than force participation, successful communities ‘build benches’ for those on the sidelines,” and make opportunities for greater involvement when appropriate.11
Wenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge: seven principles for cultivating communities of practice. Available at: http://hbswk.hbs.edu/archive/2855.html. Accessed March 17, 2013.
Principle 4: Develop Public and Private Community Spaces
Our CoP built strong connections in public spaces, such as the semi-annual meetings, as well as in private spaces among community members.
11
In 2008, EIP adopted a private electronic social networking site called EpsilenWenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge: seven principles for cultivating communities of practice. Available at: http://hbswk.hbs.edu/archive/2855.html. Accessed March 17, 2013.
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and self-funded a national EIP program coordinator to foster communication between programs. In addition to the semi-annual meetings, EIP members shared work with each other through countless conference calls, national task force groups, and other meetings. A social network analysis demonstrated high connectivity between EIP members, and the strength of connection between individual programs approached or exceeded connection to the rest of APDIM combined (unpublished data). Collaborations included a number of program site visits in which EIP program directors visited and reviewed other programs. By 2010, 4 years after inception, EIP had become a close-knit group of medical educators who collaborated regularly, replicated great ideas, and cooperated in disseminating new models through academic scholarship. As the individual offline relationships strengthened, public events such as the semi-annual meetings grew in significance.Epsilen.Available at: http://corp.epsilen.com/. Accessed August 7, 2012.
Principle 5: Focus on Value
CoPs are successful when they deliver value to the organization and to the individual members of the community.
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EIP participants have produced a significant number of workshops, posters, papers, tools, and research projects, many through collaboration. Although it is outside the scope of this article to detail all the work done by EIP programs, the Appendix (online) lists a representative bibliography of publications. Two major collaborative research projects involving more than 10 EIP programs each are currently ongoing: the Essentials of Ambulatory Care Study, using milestones in resident assessment, and the Continuity Measurement Study, measuring how ambulatory clinic structure affects patient care and learner satisfaction. Participants of these 2 initiatives have created the Educational Research Outcomes Collaborative–Internal Medicine, which now includes non-EIP programs. The first project of this new collaborative aims to determine the milestones required for assessing inpatient discharges. In addition, since 2007, EIP programs, which represent approximately 5% of APDIM, have produced or participated in 34% of APDIM workshops.At the individual level, scholarship and academic products have led to professional career development and academic promotion for a number of EIP participants. Many EIP program directors are now senior leaders within their organizations, and several associate program directors are now directors. EIP participants hold or have held several national leadership posts and have received invitations to present to the Institute of Medicine, participate in Dartmouth Leadership Institute programs, develop curricula for the Society of General Internal Medicine Patient-Centered Medical Home Education Summit, serve as faculty for Society of Hospital Medicine's Quality and Safety Educators Academy, participate in the Alliance for Academic Internal Medicine Education Redesign Committee, and partner with the American Board of Internal Medicine to develop assessment tools and curriculum. It is possible that these results could represent a selection bias, and high-achieving program directors that elected to join EIP would have been promoted or asked to join national collaboratives regardless. However, many EIP participants felt that peer mentoring within EIP was a key element of success, and they valued being in contact with like-minded people to discuss innovations as well as work-family balance and other topics outside of medical education.
Principle 6: Combine Familiarity and Excitement
“Alive” communities provide a sense of home, but also cycle in new ideas and people to challenge the status quo.
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As EIP matured and settled into regular patterns of meetings, conference calls, and projects, participants found a safe place to offer and receive advice separate from demands of their daily work. When new people joined the group and new challenges arose, the stability of EIP participant relationships provided a sturdy environment to test divergent opinions and ideas.Principle 7: Create Rhythm for the Community
CoPs must find a proper rhythm for the work. If the pace is too fast, people get overwhelmed. If too slow, they become bored and drop out.
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EIP members found that the proper rhythm was dictated primarily by their immediate needs. They met in large groups and small, in person and electronically, regularly and ad hoc, bound by the beat of personal and professional commitment to the group.In summary, successful CoPs solve problems, spread best practices, develop skills, and promote talent.
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Table 3 lists key CoP activities created by following the principles and provides examples from the EIP experience.As NAS matures, CoPs within larger organizations such as ACGME and APDIM could accelerate and sustain innovation more effectively than individual programs alone. Professional organizations and accrediting bodies cannot, however, mandate the sense of “aliveness” central to CoP success. The paradox of CoPs is that, although they are organically grown and self-organizing, they require careful cultivation over time.
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Per Wenger, professional organizations and accrediting bodies should take 3 steps to accomplish this cultivation.4
- 1.Identify potential communities within the larger groups: EIP members were self-selected out of a common desire to improve care and education. The fact that many more programs wished to participate than were chosen suggests the potential for interest in additional CoPs within APDIM.
- 2.Provide the infrastructure: RRC-IM provided modest support and space for the semi-annual EIP meetings, with the expectation that EIP programs would engage with each other between meetings. Importantly, RRC-IM did not design this work specifically or proscribe specific outcomes; instead, they let front-line program directors determine what work was most important and gave them freedom to take this work where it needed to go. As programs in NAS innovate to produce outcomes, CoPs like EIP could provide safe spaces to determine the direction and significance of these innovations.
- 3.Measure value in nontraditional ways. If EIP had been measured solely by the number of curricula developed and papers published within the first 2 years, the project would have been considered a failure. Often, the effects of CoPs are delayed and results generally appear in the work of the individual programs, not in the CoP itself.4Wenger suggests listening to member stories along the way, as RRC-IM did, to elucidate the relationship between group activities, knowledge, and performance, and to have a long arc of time for measuring success. In addition, our CoP was given a general directive to improve care and learning and not a prespecified outcome. This flexibility led to the significant breadth of work indicated in the Appendix (online) that could not have been predicted from the outset.
At its heart, the story of EIP has been the formation of a CoP focused on improving care and education for internal medicine residents. CoPs of practice can occur in any group that shares a common purpose, such as a residency program, a department of internal medicine, or a graduate medical education department of a hospital system. As professional organizations and accrediting bodies put forth initiatives such as NAS, CoPs could serve as a crucible for knowledge sharing, learning, and innovation. Further study is needed to determine whether CoPs like EIP can be replicated and to determine the ultimate impact of EIP and CoPs on medical education, health care delivery, and accreditation.
Appendix
AppendixRepresentative Bibliography of EIP Publications (Not Inclusive of All Work)
| Collaborative Work |
| Batalden MK, Warm EJ, Logio LS. Beyond curricular design of convenience: replacing noon conference with an academic half day in three internal medicine residency programs. Acad Med. 2013;88(5):644-651. |
| Chang A, Bowen J, Buranosky RA, Frankel RM, Ghosh N, Rosenblum MJ, Thompson S, Green ML. Transforming primary care training—patient-centered medical home entrustable professional activities for internal medicine residents. J Gen Intern Med. 2013;28(6):801-809. |
| Heist K, Post J, Meade LB, Brandenburg S. Do learners and teachers agree? Am J Med. 2013;126(3):270-274. |
| Leasure EL, Jones RR, Meade LB, Sanger MI, Thomas KG, Tilden VP, Bowen JL, Warm EJ. There is no “i” in teamwork in the patient centered medical home: defining teamwork competencies for academic practice. Acad Med. 2013;88(5):585-592. |
| Meade LB, Caverzagie KJ, Jones RR, O'Malley CW, Yamazaki K, Zaas A, Swing S. Playing with milestones in the educational sandbox: Q-sort results from an educational collaborative. Acad Med. 2013;88(8):1142-1148. |
| Rosenblum M, Aulakh S, Luciano G, Varney A. Competency-based progression: concept to reality, competency-based progression: concept to reality. Acad Int Med Insight. 2011;9:20-21. |
| Individual Program Work |
| Aberegg SK, O'Brien JM, Lucarelli M, Terry PB. The search-inference framework: a proposed strategy for novice clinical problem solving. Med Educ. 2008;42(4):389-395. PubMed PMID: 18338991 |
| Bump GM, Bost JE, Buranosky R, Elnicki M. Faculty member review and feedback using a sign-out checklist: improving intern written sign-out. Acad Med. 2012;87(8):1125-1131. PubMed PMID: 22722359 |
| Caverzagie KJ, Shea JA, Kogan JR. Resident identification of learning objectives after performing self-assessment based upon the ACGME core competencies. J Gen Intern Med. 2008;23(7):1024-1027. PubMed PMID: 18612737 |
| Cox LM, Logio LS. Patient safety stories: a project utilizing narratives in resident training. Acad Med. 2011;86(11):1473-1478. PubMed PMID: 21952066 |
| Crowley MJ, Barkauskas CE, Srygley FD, Kransdorf EP, LeBlanc TW, Simel DL, McNeill DB. A comparative resident site visit project: a novel approach for implementing programmatic change in the duty hours era. Acad Med. 2010;85(7):1140-1146. PubMed PMID: 20592509 |
| Gonzalo J, Herzig S, Reynolds E, Yang J. Factors associated with non-compliance during 16-hour long call shifts. J Gen Intern Med. 2012;27(11):1424-1431. doi: 10.1007/s11606-012-2047-z. Epub 2012 Apr 13. PubMed PMID: 22528621 |
| Heflin MT, Pinheiro S, Kaminetzky CP, McNeill D. ‘So you want to be a clinician-educator…’: designing a clinician-educator curriculum for internal medicine residents. Med Teach. 2009;31(6):e233-e240. PubMed PMID: 19296370 |
| Hildebrand C, Trowbridge E, Roach MA, Sullivan AG, Broman AT, Vogelman B. Resident self-assessment and self-reflection: University of Wisconsin-Madison's Five-Year Study. J Gen Intern Med. 2009;24(3):361-365. PubMed PMID: 19156469 |
| Holland R, Meyers D, Hildebrand C, Bridges AJ, Roach MA, Vogelman B. Creating champions for health care quality and safety. Am J Med Qual. 2010;25(2):102-108. PubMed PMID: 19966115 |
| Jasti H, Sheth H, Verrico M, Perera S, Bump G, Simak D, Buranosky R, Handler SM. Assessing patient safety culture of internal medicine house staff in an academic teaching hospital. J Grad Med Educ. 2009;1(1):139-145. PubMed PMID: 21975721 |
| Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ. Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination. J Hosp Med. 2012;7(7):537-542. PubMed PMID: 22592969 |
| Kimura BJ, Shaw DJ, Agan DL, Amundson SA, Ping AC, DeMaria AN. Value of a cardiovascular limited ultrasound examination using a hand-carried ultrasound device on clinical management in an outpatient medical clinic. Am J Cardiol. 2007;100(2):321-325. PubMed PMID: 17631091 |
| Leenstra JL, Beckman TJ, Reed DA, Mundell WC, Thomas KG, Krajicek BJ, Cha SS, Kolars JC, McDonald FS. Validation of a method for assessing resident physicians' quality improvement proposals. J Gen Intern Med. 2007;22(9):1330-1334. PubMed Central PMCID: PMC2219765 |
| Mathis BR, Warm EJ, Schauer DP, Holmboe E, Rouan GW. A multiple choice testing program coupled with a year-long elective experience is associated with improved performance on the internal medicine in-training examination. J Gen Intern Med. 2011;26(11):1253-1257. PubMed PMID: 21499831 |
| Meade LB, Borden SH, McArdle P, Rosenblum MJ, Picchioni MS, Hinchey KT. From theory to actual practice: creation and application of milestones in an internal medicine residency program, 2004-2010. Med Teach. 2012;34(9):717-723. PubMed PMID: 22646298 |
| Mourad M, Vidyarthi AR, Hollander H, Ranji SR. Shifting indirect patient care duties to after hours in the era of work hours restrictions. Acad Med. 2011;86(5):586-590. PubMed PMID: 21436665 |
| Nabors C, Peterson SJ, Lee WN, Mumtaz A, Shah T, Sule S, Gutwein AH, Forman L, Eskridge E, Wold E, Stallings GW, Burak KK, Karmen C, Behar CF, Carosella C, Yu S, Kar K, Gennarelli M, Bailey-Wallace G, Goldberg R, Guo G, Frishman WH. Experience with faculty supervision of an electronic resident sign-out system. Am J Med. 2010;123(4):376-381. PubMed PMID: 20362760 |
| Nabors C, Peterson SJ, Weems R, Forman L, Mumtaz A, Goldberg R, Kar K, Borges JA, Doctor I, Lubben O, Pherwani N, Frishman WH. A multidisciplinary approach for teaching systems-based practice to internal medicine residents. J Grad Med Educ. 2011;3(1):75-80. PubMed PMID: 22379526 |
| Rosenblum M, Picchioni M, Borden SH, Stefan M, et al. The Baystate Manager Model. Acad Intern Med Insight. 2007;5(2):18. |
| Salem JK, Jones RR, Sweet DB, Hasan S, Torregosa-Arcay H, Clough L. Improving care in a resident practice for patients with diabetes. J Grad Med Educ. 2011;3(2):196-202. PubMed PMID: 22655142 |
| Shunk R, Dulay M, Julian K, Cornett P, Kohlwes J, Tarter L, Hollander H, O'Brien B, O'Sullivan P. Using the American Board of Internal Medicine practice improvement modules to teach internal medicine residents practice improvement. J Grad Med Educ. 2010;2(1):90-95. PubMed PMID: 21975892 |
| Tess AV, Yang JJ, Smith CC, Fawcett CM, Bates CK, Reynolds EE. Combining clinical microsystems and an experiential quality improvement curriculum to improve residency education in internal medicine. Acad Med. 2009;84(3):326-334. PubMed PMID: 19240439 |
| Thanarajasingam U, McDonald FS, Halvorsen AJ, Naessens JM, Cabanela RL, Johnson MG, Daniels PR, Williams AW, Reed DA. Service census caps and unit-based admissions: resident workload, conference attendance, duty hour compliance, and patient safety. Mayo Clin Proc. 2012;87(4):320-327. PubMed PMID: 22469344 |
| Thomas MR, Beckman TJ, Mauck KF, Cha SS, Thomas KG. Group assessments of resident physicians improve reliability and decrease halo error. J Gen Intern Med. 2011;26(7):759-764. PubMed Central PMCID: PMC3138588 |
| Varney A, Todd C, Hingle S, Clark M. Description of a developmental criterion-referenced assessment for promoting competence in internal medicine residents. J Grad Med Educ. 2009;1(1):73-81. PubMed PMID: 21975710 |
| Warm EJ, Schauer DP, Diers T, Mathis BR, Neirouz Y, Boex JR, Rouan GW. The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP). J Gen Intern Med. 2008;23(7):921-926. PubMed PMID: 18612718 |
| Were MC, Li X, Kesterson J, Cadwallader J, Asirwa C, Khan B, Rosenman MB. Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. J Gen Intern Med. 2009;24(9):1002-1006. PubMed PMID: 19575268 |
| West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306(9):952-960. PubMed PMID: 21900135 |
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Article Info
Footnotes
Funding: None.
Conflict of Interest: None.
Authorship: All authors had access to the data and a role in writing the manuscript.
Identification
Copyright
© 2013 Alliance for Academic Internal Medicine. Published by Elsevier Inc. All rights reserved.
