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Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees

Published:December 29, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.12.005
      Perspectives Viewpoints
      • To increase resident satisfaction with primary care training, institutions must invest in primary care, optimize the electronic health record, and incorporate team-based health systems.
      • Residency programs should commit to integrating subspecialists into the ambulatory site, enhance community engagement opportunities, foster a diverse patient population, and emphasize continuity of care.
      • Faculty must commit to setting a culture of learning and engagement for trainees, while also balancing supervision and autonomy when precepting.

      Introduction

      The considerable gap in the primary care workforce of the United States is anticipated to widen over the next 10 to 15 years.
      IHS Markit
      The 2017 update: complexities of physician supply and demand: projections from 2015 to 2030.
      Numerous physician groups have called for increased focus on primary care training in medical education.
      • Holmboe ES
      • Bowen JL
      • Green M
      • et al.
      Reforming internal medicine residency training. A report from the Society of General Internal Medicine's task force for residency reform.
      • Weinberger SE
      • Smith LG
      • Collier VU
      Redesigning training for internal medicine.
      • Butkus R
      • Lane S
      • Steinmann AF
      • et al.
      Financing U.S. graduate medical education: a policy position paper of the Alliance for Academic Internal Medicine and the American College of Physicians.
      In 2009, the Accreditation Council on Graduate Medical Education (ACGME) mandated an increase for ambulatory training during internal medicine residency, requiring a minimum of 130 half-day clinics over 3 years. This increased requirement presupposes that greater exposure will inevitably lead to more primary care physicians, but some have argued it is increased exposure to high-quality, high-functioning primary care experiences that inspire trainees to contemplate a career in primary care.
      • Francis MD
      • Thomas K
      • Langan M
      • et al.
      Clinic design, key practice metrics, and resident satisfaction in internal medicine continuity clinics: findings of the educational innovations project ambulatory collaborative.
      In 2018, Stepczynski et al
      • Stepczynski J
      • Holt SR
      • Ellman MS
      • Tobin D
      • Doolittle BR
      Factors affecting resident satisfaction in continuity clinic-a systematic review.
      conducted a systematic review of all English-language articles published prior to December 2016 about physician trainee satisfaction with ambulatory training. In that review, only 2 factors were reliably associated with trainee satisfaction: minimizing outpatient/inpatient conflict and recruiting faculty dedicated to outpatient teaching. Subsequently, a 2019 scoping review of all published ambulatory training innovations since the 2009 revision of the ACGME Program Requirements identified 182 relevant articles.
      • Coyle A
      • Helenius I
      • Cruz CM
      • et al.
      A decade of teaching and learning in internal medicine ambulatory education: a scoping review.
      However, heterogeneity of the interventions described, use of nonstandardized measurement tools, and lack of patient-level outcomes assessments limited generalizability.
      Freed from the strict methodology of a systematic review, narrative reviews are useful in synthesizing the available literature when the methodologic rigor of systematic reviews fails to provide practical recommendations.
      • Ferrari R
      Writing narrative style literature reviews.
      Where evidence is lacking, expert opinion can inform recommendations. We provide a pragmatic, evidence-based narrative review of the literature, intended to offer concrete, actionable recommendations to increase resident satisfaction with primary care training.

      Methods

      The authors, each with a decade or more of leadership experience as program directors in internal medicine or pediatrics (SH, JM, BD) and clinic directors (DT, LW, ME), represent 4 distinct primary care practices in Connecticut. Beginning in November 2018, we listed all potentially relevant factors emerging from prior reviews and the authors’ own experience. Using an initial list of 15 factors, we met monthly until June 2019, deliberating about which were best supported by the literature. A final list of 10 specific factors was distributed among the authors, who reviewed the available evidence, drafted a summary, and presented to the group until consensus was reached.

      Results

      We categorized 10 recommendations into 3 major themes: institutional commitment, residency program commitment, and faculty commitment.

      Theme 1: Institutional Commitment

      Recommendation 1: Partner with institutional leaders to invest in primary care

      Keirns and Bosk
      • Keirns CC
      • Bosk CL
      Perspective: the unintended consequences of training residents in dysfunctional outpatient settings.
      argue that exposure to primary care settings will not increase interest if these settings are under-resourced, dysfunctional, and perceived as undervalued by the institution. In a cost-conscious health care system with decreasing revenues and struggling hospitals, primary care may be undervalued relative to more lucrative procedure-based subspecialties. It is particularly true of residency program-based continuity clinics that historically provide care to uninsured or underinsured patients and rarely match operational costs.
      • Nadkarni M
      • Reddy S
      • Bates CK
      • Fosburgh B
      • Babbott S
      • Holmboe E
      Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors.
      Moreover, this complex patient population has a higher prevalence of significant medical and psychiatric illness than a typical general practice,
      • Didden DG
      • Philbrick JT
      • Schorling JB
      Anxiety and depression in an internal medicine resident continuity clinic: difficult diagnoses.
      possibly contributing to further disillusionment.
      Educational leaders must impress upon institutional leadership that investing in primary care, ideally via the creation of patient-centered medical homes, is essential. Such investment leads to improved patient outcomes,
      • Tu JV
      • Chu A
      • Maclagan L
      • et al.
      Regional variations in ambulatory care and incidence of cardiovascular events.
      • Phillips RL
      • Bazemore AW
      Primary care and why it matters for U.S. health system reform.
      • Basu S
      • Berkowitz SA
      • Phillips RL
      • Bitton A
      • Landon BE
      • Phillips RS
      Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015.
      reductions in cost and health care utilization,
      • Starfield B
      • Shi L
      • Macinko J
      Contribution of primary care to health systems and health.
      ,
      • Hussey PS
      • Schneider EC
      • Rudin RS
      • Fox D
      • Lai J
      • Pollack C
      Continuity and the costs of care for chronic disease.
      and reduced physician burnout.
      • Reid RJ
      • Coleman K
      • Johnson EA
      • et al.
      The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers.
      In addition to financial investment, institutions must also culturally embrace the importance of primary care. A hidden curriculum may disparage primary care, making it less likely to generate interest among both undergraduate and graduate medical education trainees.
      • Erikson CE
      • Danish S
      • Jones KC
      • Sandberg SF
      • Carle AC
      The role of medical school culture in primary care career choice.
      • Long T
      • Chaiyachati K
      • Bosu O
      • et al.
      Why aren't more primary care residents going into primary care? A qualitative study.
      • Oser TK
      • Haidet P
      • Lewis PR
      • Mauger DT
      • Gingrich DL
      • Leong SL
      Frequency and negative impact of medical student mistreatment based on specialty choice: a longitudinal study.
      • Wainwright D
      • Harris M
      • Wainwright E
      How does ‘banter’ influence trainee doctors’ choice of career? A qualitative study.

      Recommendation 2: Maximize ambulatory functionality of electronic health records (EHRs)

      Although some EHRs accentuate ambulatory functionality, others emphasize inpatient utilization. Institutions must select and support an EHR well suited to both venues. Although the EHR has the potential to enhance data retrieval, care coordination, and medication safety, it can also increase time required for documentation, cause work disruptions, and increase electronic administrative tasks.
      • Zulman DM
      • Shah NH
      • Verghese A
      Evolutionary pressures on the electronic health record: caring for complexity.
      ,
      • Nguyen L
      • Bellucci E
      • Nguyen LT
      Electronic health records implementation: an evaluation of information system impact and contingency factors.
      These challenges negatively impact satisfaction, and institutional leaders must support efforts to address them. Gidwani et al
      • Gidwani R
      • Nguyen C
      • Kofoed A
      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      demonstrated that the use of scribes is associated with higher provider satisfaction, while computerized physician order entry is associated with increased provider burnout.
      • Shanafelt TD
      • Dyrbye LN
      • Sinsky C
      • et al.
      Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction.
      Optimizing EHR workflows and minimizing burdensome electronic tasks will be appreciated by trainees and faculty alike.
      Importantly, a capable EHR system should also facilitate effective panel management and population health. ACGME promotes this training priority with milestones focusing on practice data, quality improvement (QI) activities,
      The Accreditation Council for Graduate Medical Education and The American Board of Internal Medicine
      The Internal Medicine Milestone Project.
      and community health.
      Society of Teachers of Family Medicine (STFM)
      ACGME releases new milestones for Family Medicine residencies.
      While EHRs can provide individualized and mostly automated practice-level data, few studies in the literature have assessed best practices in this area.
      • Holmboe ES
      • Prince L
      • Green M
      Teaching and improving quality of care in a primary care internal medicine residency clinic.
      ,
      • Thomas KG
      • Thomas MR
      • Stroebel RJ
      • et al.
      Use of a registry-generated audit, feedback, and patient reminder intervention in an internal medicine resident clinic–a randomized trial.
      Little dedicated time for such efforts, small resident panel sizes, and misattribution of panel data are difficult challenges to address. However, Haynes et al
      • Haynes C
      • Yamamoto M
      • Dashiell-Earp C
      • Gunawardena D
      • Gupta R
      • Simon W
      Continuity clinic practice feedback curriculum for residents: a model for ambulatory education.
      showed improvement in ability to receive, interpret, and understand practice data with only a brief amount of educational time, so it can be overcome.

      Recommendation 3: Team-based care and interprofessionalism

      In a 2016 report, the Association of American Medical Colleges concluded that team-based care was one of 10 essential components of a highly-functioning primary care clinic.
      • Bodenheimer T
      • Gupta R
      • Dubé K
      • et al.
      High-functioning primary care residency clinics: building blocks for providing excellent care and training.
      Well-developed teams allow physicians to manage care in demanding environments and provide patient continuity when a resident is not in clinic. Additionally, team structure and culture have been associated with lower burnout among providers in primary care.
      • Willard-Grace R
      • Hessler D
      • Rogers E
      • Dube K
      • Bodenheimer T
      • Grumbach K
      Team structure and culture are associated with lower burnout in primary care.
      The Association of American Medical Colleges offers 9 elements of team-based care: stable team structure; co-location; sharing the care; defined roles with training and skills checks; standing orders and protocols; defined workflows; staffing ratios adequate to facilitate new roles; ground rules; and enhanced team communication with meetings, huddles, and minute-to-minute interaction. Residents who work with medical assistants and nurses throughout their tenure develop collaborative professional relationships, cultivating the skills needed to practice within a high-functioning team.
      • Chen EH
      • Thom DH
      • Hessler DM
      • et al.
      Using the Teamlet Model to Improve Chronic Care in an Academic Primary Care Practice.
      ,
      • Block L
      • LaVine N
      • Verbsky J
      • et al.
      Do medical residents perform patient-centered medical home tasks? A mixed-methods study.
      In such a team-based model, all members contribute meaningfully to patient care and function at the highest level of their license. Also, patients interact consistently with at least one familiar member of a trusted team.

      Theme 2: Commitment of Residency Program

      Recommendation 4: Integration of subspecialties into practice site

      Access to specialty care is essential for appropriate primary care delivery. Ideally, only limited specialist support would be needed, although the literature suggests otherwise. For example, using a sample of 845,243 visits from the National Ambulatory Medical Care Survey, one study found the referral rate for Medicare beneficiaries increased 10% over 10 years.
      • Barnett ML
      • Song Z
      • Landon BE
      Trends in physician referrals in the United States, 1999-2009.
      Likewise, in a study of community health centers, about 25% of visits resulted in medically necessary referrals.
      • Cook NL
      • Hicks LS
      • O'Malley AJ
      • Keegan T
      • Guadagnoli E
      • Landon BE
      Access to specialty care and medical services in community health centers.
      Unfortunately, residency clinics often cannot meet the demand for specialty access, resulting in long wait times and risk for poor health outcomes.
      • Forrest CB
      • Shadmi E
      • Nutting PA
      • Starfield B
      Specialty referral completion among primary care patients: results from the ASPN Referral Study.
      To address this problem, primary care providers should expand their skillset to include focused specialty care in a few highly needed areas such as diabetes or addiction. Further, embedding specialty services within primary care can improve access. For example, a Mayo Clinic study found that integrated spine specialists reduced referrals to the spine specialty clinic by 70% over 1 year.
      • Howard B
      • Fischer S
      • Jensen J
      • Torrens-Burton J
      Embedding a specialist within primary care to improve access for low-complexity indications.
      Alternatively, hospitals and teaching programs can collaborate with specialists to host an internal specialty clinic co-staffed by specialists and trainees, which offers the unique opportunity for residents to deliver consultative care—under the supervision of a specialist—on their own primary care patients, enhancing continuity of care, valuable educational opportunities, and potentially improving resident satisfaction.
      • Coyle A
      • Helenius I
      • Cruz CM
      • et al.
      A decade of teaching and learning in internal medicine ambulatory education: a scoping review.
      Over time, it may improve the expertise of the primary care team to deliver meaningful specialty care without external support.
      • Holt SR
      • Segar N
      • Cavallo DA
      • Tetrault JM
      The addiction recovery clinic: a novel, primary-care-based approach to teaching addiction medicine.
      In addition to billing for their services, the specialist can be supported by a flat fee paid by the sponsoring institution or may volunteer their time to support the teaching mission and the community.

      Recommendation 5: Community engagement and home visits

      Ambulatory care is more than the interaction between physician and patient in an office-based context. Visiting nurses, home health aides, and other home-based professionals are key to comprehensive care, especially with complicated patients. Exposing learners to these important experts enhances their understanding of the complex nature of ambulatory care. The ACGME milestone of system-based practice requires that all residents are able to “work effectively in various health care settings … coordinate patient care within the health care system … and work in interprofessional teams.”
      Accreditation Council for Graduate Medical Education (ACGME)
      ACGME Program Requirements for Graduate Medical Education in Internal Medicine.
      Partnering with community agencies and engaging in home-based care addresses these requirements. Further, incorporating home-based care into their own practice (ie, home visits) engages trainees with the patient's environment, uncovers barriers to care, and reveals hidden forces that impact a patient's health.
      • Klitzner TS
      • Rabbitt LA
      • Chang RR
      Benefits of care coordination for children with complex disease: a pilot medical home project in a resident teaching clinic.
      ,
      • Neale AV
      • Hodgkins BJ
      • Demers RY
      The home visit in resident education: program description and evaluation.
      A study of a home visit program at a family medicine residency program showed improved understanding of community services, enhanced assessment skills, and improved overall care.
      • Laditka SB
      • Fischer M
      • Mathews KB
      • Sadlik JM
      • Warfel ME
      There's no place like home: evaluating family medicine residents' training in home care.
      Another study among pediatric residents that included pre- and post-testing after implementation of a home visitation program demonstrated improvement in overall care of the patient, understanding of home and community resources, excitement about home visits, and comfort in the neighborhood. Importantly, these changes showed a sustained effect 14 to 22 months after the intervention.
      • Tschudy MM
      • Platt RE
      • Serwint JR
      Extending the medical home into the community: a newborn home visitation program for pediatric residents.
      Community engagement through home visits and other community-based activities provides meaningful context for comprehensive patient care.

      Recommendation 6: Aim for a diverse patient population

      Diversity in clinic patient characteristics and medical conditions are associated with higher resident satisfaction.
      • Long T
      • Chaiyachati K
      • Bosu O
      • et al.
      Why aren't more primary care residents going into primary care? A qualitative study.
      ,
      • Sisson SD
      • Boonyasai R
      • Baker-Genaw K
      • Silverstein J
      Continuity clinic satisfaction and valuation in residency training.
      • Barnett DR
      • Bass 3rd, PF
      • Griffith 3rd, CH
      • Caudill TS
      • Wilson JF
      Determinants of resident satisfaction with patients in their continuity clinic.
      • Serwint JR
      • Feigelman S
      • Dumont-Driscoll M
      • et al.
      Factors associated with resident satisfaction with their continuity experience.
      Gender balance and a diversity of patient ages are also associated with improved satisfaction among internal medicine residents, while a lack of patient diversity may dissuade residents from pursuing primary care.
      • Long T
      • Chaiyachati K
      • Bosu O
      • et al.
      Why aren't more primary care residents going into primary care? A qualitative study.
      ,
      • Sisson SD
      • Boonyasai R
      • Baker-Genaw K
      • Silverstein J
      Continuity clinic satisfaction and valuation in residency training.
      Similarly, for pediatric residents, higher clinic satisfaction is associated with diverse pediatric patients from all socioeconomic groups, as well as a balance of adolescents and newborns.
      • Barnett DR
      • Bass 3rd, PF
      • Griffith 3rd, CH
      • Caudill TS
      • Wilson JF
      Determinants of resident satisfaction with patients in their continuity clinic.
      In addition, higher satisfaction among both internal medicine and pediatrics residents has been linked to patient panels with a well-balanced spectrum of health problems not dominated by pain, psychiatric issues, or chronic diseases.
      • Serwint JR
      • Feigelman S
      • Dumont-Driscoll M
      • et al.
      Factors associated with resident satisfaction with their continuity experience.
      For a range of structural reasons, ambulatory training sites may serve a patient population skewed in terms of patient sex, age, social class, health status, or medical conditions.
      • Charlson ME
      • Karnik J
      • Wong M
      • McCulloch CE
      • Hollenberg JP
      Does experience matter?.
      • Serwint JR
      • Thoma KA
      • Dabrow SM
      • et al.
      Comparing patients seen in pediatric resident continuity clinics and national ambulatory medical care survey practices: a study from the continuity research network.
      • Zallman L
      • Ma J
      • Xiao L
      • Lasser KE
      Quality of US primary care delivered by resident and staff physicians.
      Educators should aim to maximize patient diversity for trainees by, when possible, balancing panels across patient characteristics (eg, age, sex) and offering opportunities for block rotations at ambulatory sites with complementary patient populations.

      Recommendation 7: Continuity and fidelity between residents, patients, and faculty

      Continuity with a defined panel of patients is essential for meaningful practice-based learning. Studies indicate that continuity of care is associated with fewer patient hospitalizations and emergency department visits, increased adherence to medications, and improved patient satisfaction.
      • Cabana MD
      • Jee SH
      Does continuity of care improve patient outcomes?.
      ,
      • Brookhart MA
      • Patrick AR
      • Schneeweiss S
      • et al.
      Physician follow-up and provider continuity are associated with long-term medication adherence: a study of the dynamics of statin use.
      Creating continuity between patients and residents may require several components including: flexible patient scheduling (eg, same-day appointments), ability to reliably predict resident schedules, and team-based care that creates a familiar cadre of providers for an individual patient. By creating teams of 5 or 6 residents who cover each another, one clinic improved continuity with primary care provider to primary care team from roughly 41% to 89%. It was accompanied by a significant no-show/cancellation rate decrease from 10.6% to 4.6%.
      • Butler M
      • Kim H
      • Sansone R
      Improved continuity of care in a resident clinic.
      Additionally, continuity between residents and faculty is also important and allows for the development of meaningful mentorship and substantive feedback over time.
      With continuity in mind, the Residency Review Committee for Internal Medicine recognizes that ambulatory education programs must minimize the conflict between inpatient and outpatient experiences.
      Accreditation Council for Graduate Medical Education (ACGME)
      ACGME Program Requirements for Graduate Medical Education in Internal Medicine.
      In response, numerous programs have implemented “X+Y” scheduling, in which inpatient rotations (X) are separated in time from ambulatory block rotations (Y). Initially described in 2010,
      • Mariotti JL
      • Shalaby M
      • Fitzgibbons JP
      The 4:1 schedule: a novel template for internal medicine residencies.
      distinct X+Y block schedules have been shown to increase resident satisfaction with the ambulatory experience and improve resident patient continuity.
      • Chaudhry SI
      • Balwan S
      • Friedman KA
      • et al.
      Moving forward in GME reform: a 4 + 1 model of resident ambulatory training.
      • Harrison JW
      • Ramaiya A
      • Cronkright P
      Restoring emphasis on ambulatory internal medicine training–the 3:1 model.
      • Hoskote S
      • Mehta B
      • Fried E
      The six-plus-two ambulatory care model: a necessity in today's Internal Medicine Residency Program.
      Distinct ambulatory block rotations also provide dedicated time for didactic conferences, subspecialty experiences, panel management, and QI activities. Importantly, successful implementation of X+Y scheduling involves careful consideration, as transitioning to this model involves substantial scheduling and cultural changes.
      • Shalaby M
      • Yaich S
      • Donnelly J
      • Chippendale R
      • DeOliveira MC
      • Noronha C
      X + Y scheduling models for internal medicine residency programs–a look back and a look forward.

      Recommendation 8: Participation in clinic operations

      Resident engagement in clinic operations is a hallmark of highly functioning residency clinic practices and meets an important training need. Empowering residents to become tomorrow's primary care leaders requires experience engaging with institutional leadership.
      • Bodenheimer T
      • Gupta R
      • Dubé K
      • et al.
      High-functioning primary care residency clinics: building blocks for providing excellent care and training.
      Participation in clinic operations also allows a trainee to become an involved stakeholder, thus promoting a greater sense of ownership while simultaneously allowing increased awareness of their clinical microsystem. The trainee learns to access a system's resources more efficiently, influence clinical processes, and drive QI efforts. Furthermore, engagement in clinic operations allows residents to influence the shared values and common goals of the practice, belong to a larger leadership community, and promote connection with colleagues, all of which are strategies that may reduce physician burnout.
      • Shanafelt TD
      • Noseworthy JH
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.

      Theme 3: Commitment by Faculty

      Recommendation 9: Enthusiastic, dedicated and well-trained primary care faculty

      Faculty set the culture for learning and engagement for the trainee. Recruitment of faculty who model excellence for primary care and enthusiasm for teaching correlates with improved trainee experience.
      • Sisson SD
      • Boonyasai R
      • Baker-Genaw K
      • Silverstein J
      Continuity clinic satisfaction and valuation in residency training.
      ,
      • Serwint JR
      • Feigelman S
      • Dumont-Driscoll M
      • et al.
      Factors associated with resident satisfaction with their continuity experience.
      Satisfaction with faculty mentorship is also associated with increased likelihood of choosing a career in general internal medicine.
      • Peccoralo LA
      • Tackett S
      • Ward L
      • et al.
      Resident satisfaction with continuity clinic and career choice in general internal medicine.
      While faculty may have other duties as educators, we believe faculty preceptors should be well supported and well recognized in their role, potentially through the provision of awards or formalized titles that acknowledge teaching excellence in the clinic. Such recognition should serve as an important factor for salary support and promotion. Faculty development should also be supported and encouraged, including training in teaching techniques (eg, observation, feedback, and evaluation) and attendance at educational and primary care conferences to stay current with ACGME requirements and their clinical field. As clinician-educators, faculty should be experts in both practice and pedagogy.
      Further, we believe faculty should follow a panel of patients within the ambulatory practice because it ensures faculty ownership of practice goals and the patient experience and front-line knowledge to inform QI and research projects.
      • Gupta R
      • Barnes K
      • Bodenheimer T
      Clinic first: 6 actions to transform ambulatory residency training.
      Faculty involvement in direct patient care fosters a spirit of collaboration, mentorship, and shared goals that enhance the well-being of the residents.

      Recommendation 10: Balance supervision and autonomy when precepting trainees

      Clinician educators are beholden to the public to ensure patient safety. Yet educators must also promote autonomy in trainees so they can thrive as future independent practitioners. The outpatient setting exemplifies this tension between appropriate supervision and preserved autonomy with Medicare's Primary Care Exception Rule (PCER). Preceptors may bill without interacting directly with the patient—an extraordinary display of trust toward interns only 6 months into their training.
      • Tobin DG
      • Doolittle BR
      • Ellman MS
      • Ruser CB
      • Brienza RS
      • Genao I
      Modifying the primary care exception rule to require competency-based assessment.
      Overreliance on PCER may undermine the principles of “deliberate practice,” which asserts that competence can only be achieved by repeated direct observations with feedback that is timely, specific, and actionable.
      • van de Wiel MWJ
      • Van den Bossche P
      • Janssen S
      • Jossberger H
      Exploring deliberate practice in medicine: how do physicians learn in the workplace?.
      Precepting that occurs exclusively in the conference room is unlikely to foster deliberate practice, and likely fails to unlock the full potential of trainees.
      While use of PCER may be appropriate at times, we suggest faculty should maximize opportunities for observation and feedback. One well-studied approach is to promote “Precepting in the Presence of the Patient.”
      • Power DV
      • Rosenbaum ME
      • Hanson L
      • et al.
      Precepting medical students in the patient's presence: an educational randomized trial in family medicine clinic.
      ,
      • Heaton CJ
      Patient witnessed precepting: faster precepting that is effective and fun.
      With this approach, residents or medical students briefly outline for their attending the agenda items of the visit, sensitive issues, and areas of uncertainty outside of the room. The trainee and preceptor enter the room and the trainee, using patient-centered language, presents the case to the attending. In this way, trainees practice and elicit feedback on patient-centered communication, physical diagnosis, and patient-assessment skills. This approach has been well received by students, residents, faculty, and patients alike.
      • Power DV
      • Rosenbaum ME
      • Hanson L
      • et al.
      Precepting medical students in the patient's presence: an educational randomized trial in family medicine clinic.
      ,
      • Anderson RJ
      • Cyran E
      • Schilling L
      • et al.
      Outpatient case presentations in the conference room versus examination room: results from two randomized controlled trials.
      • Happel JP
      • Ritter JB
      • Neubauer BE
      Optimizing the balance between supervision and autonomy in training.
      • Petersen K
      • Rosenbaum ME
      • Kreiter CD
      • Thomas A
      • Vogelgesang SA
      • Lawry GV
      A randomized controlled study comparing educational outcomes of examination room versus conference room staffing.

      Discussion

      Fostering a high-quality ambulatory experience for our trainees is critical for their professional development and the patients they serve. Numerous studies have evaluated important elements to crafting a well-organized educational experience, such as optimizing the EHR, arranging schedules to ensure continuity and team-based care, supporting the clinic with appropriate resources, and encouraging a well-trained faculty.
      • Stepczynski J
      • Holt SR
      • Ellman MS
      • Tobin D
      • Doolittle BR
      Factors affecting resident satisfaction in continuity clinic-a systematic review.
      ,
      • Coyle A
      • Helenius I
      • Cruz CM
      • et al.
      A decade of teaching and learning in internal medicine ambulatory education: a scoping review.
      However, most studies addressed specific challenges within a single institution and were of small scale and short duration. Generalizing such findings to other residency programs is difficult. We believe that this review, informed by both literature and collective experience, serves as a helpful roadmap for other institutions.
      We have categorized our 10 recommendations into 3 overarching themes—institutional, residency program, and faculty commitment. While some recommendations may belong in more than one category, we believe these 3 themes effectively incorporate the essential elements for a high-quality educational experience.
      Limitations should be recognized. It is possible we overlooked a key study that could have informed findings. Likewise, we augmented the findings of a literature review with our own expert opinion and acknowledge the possibility of selection bias. However, while the authors represent a single institution, we care for diverse patients in 4 different primary care settings within a large academic medical center. Although we assert our recommendations are generalizable to a wide variety of clinic settings, we recognize they may be best suited for academic medical centers. We also acknowledge that our perspective as general internists and pediatricians may neglect some factors particular to family medicine residency training.

      Conclusion

      A high-quality learning climate within ambulatory training sites shows promise to inspire the next generation of physicians to pursue primary care. Institutional support, residency program commitment, and engaged, expert faculty are all required to make it a reality. When elements are missing, the clinical and educational enterprise will struggle. This review highlights the creativity and leadership of many clinician educators who have made important strides in improving ambulatory education.

      References

        • IHS Markit
        The 2017 update: complexities of physician supply and demand: projections from 2015 to 2030.
        IHS Markit, Washington, DC2017 (Available at: https://www.researchgate.net/profile/Tim_Dall/publication/315156643_The_2017_Update_Complexities_of_Physician_Supply_and_Demand_Projections_from_2015_to_2030/links/58cbf570a6fdcca17870a691/The-2017-Update-Complexities-of-Physician-Supply-and-Demand-Projections-from-2015-to-2030.pdf. Accessed January 2, 2021)
        • Holmboe ES
        • Bowen JL
        • Green M
        • et al.
        Reforming internal medicine residency training. A report from the Society of General Internal Medicine's task force for residency reform.
        J Gen Intern Med. 2005; 20: 1165-1172
        • Weinberger SE
        • Smith LG
        • Collier VU
        Redesigning training for internal medicine.
        Ann Intern Med. 2006; 144: 927-932
        • Butkus R
        • Lane S
        • Steinmann AF
        • et al.
        Financing U.S. graduate medical education: a policy position paper of the Alliance for Academic Internal Medicine and the American College of Physicians.
        Ann Intern Med. 2016; 165: 134-137
        • Francis MD
        • Thomas K
        • Langan M
        • et al.
        Clinic design, key practice metrics, and resident satisfaction in internal medicine continuity clinics: findings of the educational innovations project ambulatory collaborative.
        J Grad Med Educ. 2014; 6: 249-255
        • Stepczynski J
        • Holt SR
        • Ellman MS
        • Tobin D
        • Doolittle BR
        Factors affecting resident satisfaction in continuity clinic-a systematic review.
        J Gen Intern Med. 2018; 33: 1386-1393
        • Coyle A
        • Helenius I
        • Cruz CM
        • et al.
        A decade of teaching and learning in internal medicine ambulatory education: a scoping review.
        J Grad Med Educ. 2019; 11: 132-142
        • Ferrari R
        Writing narrative style literature reviews.
        Med Writ. 2015; 24: 230-235
        • Keirns CC
        • Bosk CL
        Perspective: the unintended consequences of training residents in dysfunctional outpatient settings.
        Acad Med. 2008; 83: 498-502
        • Nadkarni M
        • Reddy S
        • Bates CK
        • Fosburgh B
        • Babbott S
        • Holmboe E
        Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors.
        J Gen Intern Med. 2011; 26: 16-20
        • Didden DG
        • Philbrick JT
        • Schorling JB
        Anxiety and depression in an internal medicine resident continuity clinic: difficult diagnoses.
        Int J Psychiatry Med. 2001; 31: 155-167
        • Tu JV
        • Chu A
        • Maclagan L
        • et al.
        Regional variations in ambulatory care and incidence of cardiovascular events.
        CMAJ. 2017; 189: E494-e501
        • Phillips RL
        • Bazemore AW
        Primary care and why it matters for U.S. health system reform.
        Health Aff (Millwood). 2010; 29: 806-810
        • Basu S
        • Berkowitz SA
        • Phillips RL
        • Bitton A
        • Landon BE
        • Phillips RS
        Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015.
        JAMA Intern Med. 2019; 179: 506-514
        • Starfield B
        • Shi L
        • Macinko J
        Contribution of primary care to health systems and health.
        Milbank Q. 2005; 83: 457-502
        • Hussey PS
        • Schneider EC
        • Rudin RS
        • Fox D
        • Lai J
        • Pollack C
        Continuity and the costs of care for chronic disease.
        JAMA Intern Med. 2014; 174: 742-748
        • Reid RJ
        • Coleman K
        • Johnson EA
        • et al.
        The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers.
        Health Aff (Millwood). 2010; 29: 835-843
        • Erikson CE
        • Danish S
        • Jones KC
        • Sandberg SF
        • Carle AC
        The role of medical school culture in primary care career choice.
        Acad Med. 2013; 88: 1919-1926
        • Long T
        • Chaiyachati K
        • Bosu O
        • et al.
        Why aren't more primary care residents going into primary care? A qualitative study.
        J Gen Intern Med. 2016; 31: 1452-1459
        • Oser TK
        • Haidet P
        • Lewis PR
        • Mauger DT
        • Gingrich DL
        • Leong SL
        Frequency and negative impact of medical student mistreatment based on specialty choice: a longitudinal study.
        Acad Med. 2014; 89: 755-761
        • Wainwright D
        • Harris M
        • Wainwright E
        How does ‘banter’ influence trainee doctors’ choice of career? A qualitative study.
        BMC Med Educ. 2019; 19: 104
        • Zulman DM
        • Shah NH
        • Verghese A
        Evolutionary pressures on the electronic health record: caring for complexity.
        JAMA. 2016; 316: 923-924
        • Nguyen L
        • Bellucci E
        • Nguyen LT
        Electronic health records implementation: an evaluation of information system impact and contingency factors.
        Int J Med Inform. 2014; 83: 779-796
        • Gidwani R
        • Nguyen C
        • Kofoed A
        • et al.
        Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
        Ann Fam Med. 2017; 15: 427-433
        • Shanafelt TD
        • Dyrbye LN
        • Sinsky C
        • et al.
        Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction.
        Mayo Clin Proc. 2016; 91: 836-848
        • The Accreditation Council for Graduate Medical Education and The American Board of Internal Medicine
        The Internal Medicine Milestone Project.
        2015 (Available at:https://www.acgme.org/portals/0/pdfs/milestones/internalmedicinemilestones.pdf. Accessed January 2, 2021)
        • Society of Teachers of Family Medicine (STFM)
        ACGME releases new milestones for Family Medicine residencies.
        2019 (Available at:https://stfm.org/news/2019news/10-30_new-family-medicine-milestones/. Accessed February 5, 2020)
        • Holmboe ES
        • Prince L
        • Green M
        Teaching and improving quality of care in a primary care internal medicine residency clinic.
        Acad Med. 2005; 80: 571-577
        • Thomas KG
        • Thomas MR
        • Stroebel RJ
        • et al.
        Use of a registry-generated audit, feedback, and patient reminder intervention in an internal medicine resident clinic–a randomized trial.
        J Gen Intern Med. 2007; 22: 1740-1744
        • Haynes C
        • Yamamoto M
        • Dashiell-Earp C
        • Gunawardena D
        • Gupta R
        • Simon W
        Continuity clinic practice feedback curriculum for residents: a model for ambulatory education.
        J Grad Med Educ. 2019; 11: 189-195
        • Bodenheimer T
        • Gupta R
        • Dubé K
        • et al.
        High-functioning primary care residency clinics: building blocks for providing excellent care and training.
        2016 (Available at:https://store.aamc.org/downloadable/download/sample/sample_id/126/. Accessed January 2, 2021)
        • Willard-Grace R
        • Hessler D
        • Rogers E
        • Dube K
        • Bodenheimer T
        • Grumbach K
        Team structure and culture are associated with lower burnout in primary care.
        J Am Board Fam Med. 2014; 27: 229-238
        • Chen EH
        • Thom DH
        • Hessler DM
        • et al.
        Using the Teamlet Model to Improve Chronic Care in an Academic Primary Care Practice.
        J Gen Intern Med. 2010; 25: 610-614
        • Block L
        • LaVine N
        • Verbsky J
        • et al.
        Do medical residents perform patient-centered medical home tasks? A mixed-methods study.
        Med Educ Online. 2017; 221352434
        • Barnett ML
        • Song Z
        • Landon BE
        Trends in physician referrals in the United States, 1999-2009.
        Arch Intern Med. 2012; 172: 163
        • Cook NL
        • Hicks LS
        • O'Malley AJ
        • Keegan T
        • Guadagnoli E
        • Landon BE
        Access to specialty care and medical services in community health centers.
        Health Aff (Millwood). 2007; 26: 1459-1468
        • Forrest CB
        • Shadmi E
        • Nutting PA
        • Starfield B
        Specialty referral completion among primary care patients: results from the ASPN Referral Study.
        Ann Fam Med. 2007; 5: 361-367
        • Howard B
        • Fischer S
        • Jensen J
        • Torrens-Burton J
        Embedding a specialist within primary care to improve access for low-complexity indications.
        in: Presented at: American College of Healthcare Executives, Chicago, Illinois2019 (Available at:https://www.ache.org/-/media/ache/learning-center/research/narrative1.pdf?la=en&hash=8DB2A9C512748A031BCA6CFBA66EF73F5AC629D8. Accessed January 2, 2021)
        • Holt SR
        • Segar N
        • Cavallo DA
        • Tetrault JM
        The addiction recovery clinic: a novel, primary-care-based approach to teaching addiction medicine.
        Acad Med. 2017; 92: 680-683
        • Accreditation Council for Graduate Medical Education (ACGME)
        ACGME Program Requirements for Graduate Medical Education in Internal Medicine.
        Accreditation Council for Graduate Medical Education, Chicago2017
        • Klitzner TS
        • Rabbitt LA
        • Chang RR
        Benefits of care coordination for children with complex disease: a pilot medical home project in a resident teaching clinic.
        J Pediatr. 2010; 156: 1006-1010
        • Neale AV
        • Hodgkins BJ
        • Demers RY
        The home visit in resident education: program description and evaluation.
        Fam Med. 1992; 24: 36-40
        • Laditka SB
        • Fischer M
        • Mathews KB
        • Sadlik JM
        • Warfel ME
        There's no place like home: evaluating family medicine residents' training in home care.
        Home Health Care Serv Q. 2002; 21: 1-17
        • Tschudy MM
        • Platt RE
        • Serwint JR
        Extending the medical home into the community: a newborn home visitation program for pediatric residents.
        Acad Pediatr. 2013; 13: 443-450
        • Sisson SD
        • Boonyasai R
        • Baker-Genaw K
        • Silverstein J
        Continuity clinic satisfaction and valuation in residency training.
        J Gen Intern Med. 2007; 22: 1704-1710
        • Barnett DR
        • Bass 3rd, PF
        • Griffith 3rd, CH
        • Caudill TS
        • Wilson JF
        Determinants of resident satisfaction with patients in their continuity clinic.
        J Gen Intern Med. 2004; 19: 456-459
        • Serwint JR
        • Feigelman S
        • Dumont-Driscoll M
        • et al.
        Factors associated with resident satisfaction with their continuity experience.
        Ambul Pediatr. 2004; 4: 4-10
        • Charlson ME
        • Karnik J
        • Wong M
        • McCulloch CE
        • Hollenberg JP
        Does experience matter?.
        J Gen Intern Med. 2005; 20: 497-503
        • Serwint JR
        • Thoma KA
        • Dabrow SM
        • et al.
        Comparing patients seen in pediatric resident continuity clinics and national ambulatory medical care survey practices: a study from the continuity research network.
        Pediatrics. 2006; 118: e849-e858
        • Zallman L
        • Ma J
        • Xiao L
        • Lasser KE
        Quality of US primary care delivered by resident and staff physicians.
        J Gen Intern Med. 2010; 25: 1193-1197
        • Cabana MD
        • Jee SH
        Does continuity of care improve patient outcomes?.
        J Fam Pract. 2004; 53: 974-980
        • Brookhart MA
        • Patrick AR
        • Schneeweiss S
        • et al.
        Physician follow-up and provider continuity are associated with long-term medication adherence: a study of the dynamics of statin use.
        Arch Intern Med. 2007; 167: 847-852
        • Butler M
        • Kim H
        • Sansone R
        Improved continuity of care in a resident clinic.
        Clin Teach. 2017; 14: 45-48
        • Mariotti JL
        • Shalaby M
        • Fitzgibbons JP
        The 4:1 schedule: a novel template for internal medicine residencies.
        J Grad Med Educ. 2010; 2: 541-547
        • Chaudhry SI
        • Balwan S
        • Friedman KA
        • et al.
        Moving forward in GME reform: a 4 + 1 model of resident ambulatory training.
        J Gen Intern Med. 2013; 28: 1100-1104
        • Harrison JW
        • Ramaiya A
        • Cronkright P
        Restoring emphasis on ambulatory internal medicine training–the 3:1 model.
        J Grad Med Educ. 2014; 6: 742-745
        • Hoskote S
        • Mehta B
        • Fried E
        The six-plus-two ambulatory care model: a necessity in today's Internal Medicine Residency Program.
        J Med Educ Perspect. 2012; 1: 16-19
        • Shalaby M
        • Yaich S
        • Donnelly J
        • Chippendale R
        • DeOliveira MC
        • Noronha C
        X + Y scheduling models for internal medicine residency programs–a look back and a look forward.
        J Grad Med Educ. 2014; 6: 639-642
        • Shanafelt TD
        • Noseworthy JH
        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
        Mayo Clin Proc. 2017; 92: 129-146
        • Peccoralo LA
        • Tackett S
        • Ward L
        • et al.
        Resident satisfaction with continuity clinic and career choice in general internal medicine.
        J Gen Intern Med. 2013; 28: 1020-1027
        • Gupta R
        • Barnes K
        • Bodenheimer T
        Clinic first: 6 actions to transform ambulatory residency training.
        J Grad Med Educ. 2016; 8: 500-503
        • Tobin DG
        • Doolittle BR
        • Ellman MS
        • Ruser CB
        • Brienza RS
        • Genao I
        Modifying the primary care exception rule to require competency-based assessment.
        Acad Med. 2017; 92: 331-334
        • van de Wiel MWJ
        • Van den Bossche P
        • Janssen S
        • Jossberger H
        Exploring deliberate practice in medicine: how do physicians learn in the workplace?.
        Adv Health Sci Educ Theory Pract. 2011; 16: 81-95
        • Power DV
        • Rosenbaum ME
        • Hanson L
        • et al.
        Precepting medical students in the patient's presence: an educational randomized trial in family medicine clinic.
        Fam Med. 2017; 49: 97-105
        • Heaton CJ
        Patient witnessed precepting: faster precepting that is effective and fun.
        Fam Med. 2009; 41: 696-698
        • Anderson RJ
        • Cyran E
        • Schilling L
        • et al.
        Outpatient case presentations in the conference room versus examination room: results from two randomized controlled trials.
        Am J Med. 2002; 113: 657-662
        • Happel JP
        • Ritter JB
        • Neubauer BE
        Optimizing the balance between supervision and autonomy in training.
        JAMA Intern Med. 2018; 178: 959-960
        • Petersen K
        • Rosenbaum ME
        • Kreiter CD
        • Thomas A
        • Vogelgesang SA
        • Lawry GV
        A randomized controlled study comparing educational outcomes of examination room versus conference room staffing.
        Teach Learn Med. 2008; 20: 218-224