AAMC Reporter: April 2008

Programs Give Residents Ample Outpatient Opportunities

Christiana Care Health System residents (l-r) Blake Gustafson, M.D., and Jennifer Roth, M.D., with Family and Community Medicine Residency Program Director Jennifer M. Naticchia, M.D., provide care to Dawn Baker.

Given the choice, most patients would prefer a doctor's office visit to a hospital stay. With technology improving so that many procedures can be performed outside hospital environs (and often with a lower price tag) more and more patients are being treated in outpatient or ambulatory care facilities. Accordingly, the number of patient care physicians with office-based practices is growing too—up to 560,000 in 2005 from 490,000 five years before, according to the American Medical Association.

Cognizant of this shift, residency program faculty are reinventing their curricula to home in on the ambulatory arena. Their goal is to improve how residents provide outpatient care both during their training and once they enter practice. By providing relevant learning experiences that will better prepare doctors for their future careers, these programs also hope to reverse physician dissatisfaction with the primary care field.

Ongoing patient relationships are important in ambulatory care, so these restructured curricula allow residents to treat the same patients over an extended period of time. Assessing patients in the span of a short doctor's office visit is another element, and a skill that residents can hone in these ambulatory-intensive experiences.

The Christiana Care Health System in Delaware teaches residents some administrative practice components, such as billing, using electronic health records, and finding a home nurse or other services for patients. Christiana's family and community medicine department's residency program introduced its ambulatory-focused curriculum in July 2007. This was a response to the Future of Family Medicine report, a 2004 report that called for better patient care and greater physician efficiency. More exposure to an office environment could help in these regards, said program director Jennifer M. Naticchia, M.D.

"When trainees graduate from our program, we want them to be as productive and seasoned as possible for practice, and ready to treat people in the outpatient setting," Naticchia said. Christiana's program began through its participation in Preparing the Personal Physician for Practice (also known as P4), an initiative started by the American Academy of Family Physicians (AAFP) to trigger innovation in family medicine residency programs. Christiana's premise, Naticchia said, is simple. "If we put residents in the outpatient office, they are going to learn this care."

Residents learn in various training sites including urban, suburban, private practice, and federally qualified health centers. First-year residents spend part of this time shadowing faculty. Throughout their graduate medical education, new physicians learn from direct observation, and are evaluated on their interpersonal capabilities by behavioral science faculty. Such communication skills are uniquely relevant in the outpatient arena, when physicians have smaller windows of opportunity to collect important health information from patients.

"This is a way for us to find deficiencies in residents' history taking, for example," Naticchia said. "We can then build it into the curriculum, or work on an issue with a resident individually."

From the patient perspective, more residents spending more time in the outpatient offices means better coordination of care and easier scheduling.

Christiana residents follow their patients throughout the entire continuum of treatment, including dealing with specialists. By presenting patient histories to these specialists, residents have an opportunity to collaborate with them and learn how the patient's treatment evolves past the primary care point. Some patients may require hospitalization or time in the intensive care unit, and residents follow them through these processes as well.

Preliminary feedback has been positive,Naticchia said. In one measure, first-year residents said that they felt very comfortable in the ambulatory care environment. Additional monitoring is now taking place to measure the program's success.

By providing residents with amore concentrated avenue to learn ambulatory medicine, the San Francisco Veteran's Affairs (VA)Medical Center's internal medicine redesign aimed to boost trainees' satisfaction and success in the office environment, which could translate into improved patient care. The restructuring—performed in conjunction with the University of California, San Francisco (UCSF)Medical Center—moved all residents' continuity clinic sessions to their ambulatory blocs. (Before, clinical time was spread across inpatient and outpatient blocs.)

"We felt that when residents were balancing outpatient and inpatient responsibilities, they were conflicted about where they had to be," said Patricia A. Cornett, M.D., associate chair for education in UCSF's department of medicine and a VA professor. "It was challenging to focus on their panel of [ambulatory] patients when they were thinking about responsibilities back the hospital."

A July 2007 pilot program enrolled approximately 12 residents from the VA and UCSF. Like other residents, these trainees alternated between a two-month ambulatory care rotation and a two-month hospital rotation. However, they doubled up on their 108 weekly required clinic sessions during the ambulatory bloc, and were excused from any clinic duty on ward rotations. Before each continuity clinic session, there are preclinic conferences where residents have a chance to reflect on their performance compared to their peers, Cornett said.

The program includes instruction in veteran ambulatory care, helping trainees manage veteran-specific disorders and guide patients to military support services.

Residents and patients are much happier with the new system, she said. Residents enjoy being able to focus exclusively on their panel of ambulatory patients. As with Christiana, patients who need follow-up have an easier time scheduling an appointment with their primary physicians. Because of this success, the program is expanding in July 2008. About 50 residents from the VA and the UCSF system will participate in this program. Cornett said simulators may become a part of the curriculum.

—By Elissa Fuchs

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