Ambulatory Training Research Articles

Primary Care Training and the Evolving Healthcare System

With growing numbers of patient-centered medical homes and accountable care organizations, and the potential implementation of the Patient Protection and Affordable Care Act, the provision of primary care in the United States is expanding and changing. Therefore, there is an urgent need to create more primary-care physicians and to train physicians to practice in this environment. In this article, we review the impact that the changing US healthcare system has on trainees, strategies to recruit and retain medical students and residents into primary-care internal medicine, and the preparation of trainees to work in the changing healthcare system. Recruitment methods for medical students include early preclinical exposure to patients in the primary-care setting, enhanced longitudinal patient experiences in clinical clerkships, and primary-care tracks. Recruitment methods for residents include enhanced ambulatory-care training and primary-care programs. Financial-incentive programs such as loan forgiveness may encourage trainees to enter primary care. Retaining residents in primary-care careers may be encouraged via focused postgraduate fellowships or continuing medical education to prepare primary-care physicians as both teachers and practitioners in the changing environment. Finally, to prepare primary-care trainees to effectively and efficiently practice within the changing system, educators should consider shifting ambulatory training to community-based practices, encouraging resident participation in team-based care, providing interprofessional educational experiences, and involving trainees in quality-improvement initiatives. Medical educators in primary care must think innovatively and collaboratively to effectively recruit and train the future generation of primary-care physicians.

Defining Content for a Competency-based (CanMEDS) Postgraduate Curriculum in Ambulatory Care: A Delphi Study

Ambulatory training in internal medicine has been noted to be dysfunctional and inadequate. In this study, we developed a set of competency-based outcomes specific to ambulatory care to guide the design, implementation and evaluation of instructional events to ensure that societal needs are addressed. In 2007 a Delphi technique was used to reach consensus and define the priorities for competency-based training in ambulatory care for internal medicine residents. Four groups of stakeholders in Canada participated: program directors, members of the Canadian Society of Internal Medicine, recent graduates, and residents. Two rounds of the Delphi process were required to reach consensus on a set of sixty competency-based educational objectives in ambulatory care that were classified under the CanMEDS roles. The inclusion of recent graduates in this study resulted in the addition of non-clinical topics that would have otherwise been missed, falling under roles historically viewed as being challenging to teach and evaluate (Manager, Health Advocate). This study is the first time a Delphi-process has been used to define the priorities for ambulatory care training in internal medicine under a competency-based framework. The resulting compendium of competency-based objectives provides a foundation from which educators can design, evaluate and modify existing training experiences.

Gaps In Quality Of Diabetes Care In Internal Medicine Residency Clinics Suggest The Need For Better Ambulatory Care Training

To ensure that medical residents will be prepared to deliver consistently high-quality care, they should be trained in settings that provide such care. Residents in internal medicine, particularly, need to learn good care habits in order to meet the needs of patients with diabetes and other common chronic and high-impact illnesses. To assess the strength of such training, we compared the quality of medical care provided in sixty-seven US internal medicine residency ambulatory clinics with the quality of care provided by 703 practicing general internists. We found significant quality gaps in process, intermediate outcome, and patient-experience measures. These inadequacies in ambulatory training for internal medicine residents must be addressed by policy makers and educators-for example, by accelerating the movement toward new residency curricula that emphasize competency-based training.

Early Phase 2 Inpatient Rehabilitation after Acute Coronary Syndrome Treated with Primary Percutaneous Coronary Intervention

The aim of this study was to assess the 1-yr follow-up effects of inpatient rehabilitation and its prolongation with an ambulatory training program on blood pressure and metabolic risk factors in patients after an acute coronary syndrome. A controlled (n = 20) prospective study was undertaken. The study group consisted of 54 consecutive patients participating in a 3-wk inpatient rehabilitation. Of these, 14 chose to continue the training for 3 mos (CR_In+Amb group) and 40 declined (CR_In group). Body mass index increased in the CR_In and control groups. The magnitude of change was greater in controls (2.2 ± 2.14 vs. 0.7 ± 1.70 kg/m; P < 0.05). Waist circumference increased only in the control group, and at 12 mos, it was higher than in the CR_In and CR_In+Amb groups (P < 0.05). Mean systolic and diastolic blood pressure increased in the CR_In (from 121/76 to 130/82 mm Hg; P < 0.01) and control (from 122/74 to 139/87 mm Hg; P < 0.01) groups. At 12 mos, blood pressure in the CR_In group was lower than in the control group but higher than in the CR_In+Amb group (119/77 mm Hg; P < 0.05). Total cholesterol, low-density lipoprotein cholesterol level, and triglyceride level at 12 mos were higher in the control group than in the CR_In and CR_In+Amb groups (P < 0.05). C-reactive protein decreased in the CR_In and CR_In+Amb groups (P < 0.01). Inpatient rehabilitation was associated with beneficial effects on blood lipids and C-reactive protein in coronary patients and attenuated the rise in blood pressure and adiposity indices observed in nonparticipants. Prolongation of rehabilitation with an ambulatory program improved blood pressure control.

Sleeping at Home: A New Model for a Hospital Teaching Service

The traditional marriage between teaching hospitals and residents pivots on a central prenuptial agreement: residents offer their hospitals round-the-clock patient care, and, in exchange, hospitals provide an experiential learning modality. This long-held covenant may require an update due to 3 significant changes: the increased spotlight on protecting resident education from excessive service demands; the development of hospital medicine as a specialty; and the need to provide more experiential learning in ambulatory care settings for primary care programs, including family medicine. The rapid growth of hospitalist care—84% of all teaching hospitals in the United States have at least 3 hospitalists1—has been sparked in part by pressure placed on primary care doctors to increase outpatient visits and on hospitals to reduce length of stay.2 The desire to have better work/life balance coupled with fewer inpatient admissions and increased financial demands have resulted in a decline in family medicine physicians who provide both inpatient and outpatient care. Many hospitals are moving to hospitalist care, citing improved care and decreased cost.,3,4 In 2006, the year before we implemented our new model of inpatient teaching, 62.5% of our program's new graduates entered into practice without an inpatient component. We describe a unique adult inpatient teaching service in a family medicine residency program that integrates resident teaching with hospitalist care. The novelty stems from the use of hospitalists, not residents, as the primary workforce in the hospital. By uncoupling the educational experience of teaching residents how to care for hospitalized patients from the service demands of the hospital, it is possible to achieve both of these goals and comply with duty hour limits. The added advantage of our system is that residents are able to spend more time in the outpatient setting. This gain in ambulatory training aligns with most of our residents' postgraduation plans to work as primary care physicians in the outpatient setting.

Effectiveness of automated locomotor training in patients with acute incomplete spinal cord injury: A randomized controlled multicenter trial

BackgroundA large proportion of patients with spinal cord injury (SCI) regain ambulatory function. However, during the first 3 months most of the patients are not able to walk unsupported. To enable ambulatory training at such an early stage the body weight is partially relieved and the leg movements are assisted by two therapists. A more recent approach is the application of robotic based assistance which allows for longer training duration. From motor learning science and studies including patients with stroke, it is known that training effects depend on the duration of the training. Longer trainings result in a better walking function. The aim of the present study is to evaluate if prolonged robot assisted walking training leads to a better walking outcome in patients with incomplete SCI and whether such training is feasible or has undesirable effects.Methods/DesignPatients from multiple sites with a subacute incomplete SCI and who are not able to walk independently will be randomized to either standard training (3-5 sessions per week, session duration maximum 25 minutes) or an intensive training (3-5 sessions per week, session duration minimum 50 minutes). After 8 weeks of training and 4 months later the walking ability, the occurrence of adverse events and the perceived rate of exertion as well as the patients' impression of change will be compared between groups.Trial registrationThis study is registered at clinicaltrials.gov, identifier: NCT01147185.

Is Ambulatory Care Training Anemic?

Is Ambulatory Care Training Anemic?

Internal Medicine Residency Training on Topics in Ambulatory Care: A Status Report

Internal Medicine Residency Training on Topics in Ambulatory Care: A Status Report

Ambulatory Office Organization for Internal Medicine Resident Medical Education

Residents will most effectively learn about ambulatory, systems-based practice by working in highly functional ambulatory practices; however, systems experiences in ambulatory training are thought to be highly variable. The authors sought to determine the prevalence of functional-practice characteristics at clinics where residents learn. In 2007, the authors conducted a national survey of medical directors of resident continuity clinics using a comprehensive, Web-based instrument that included both a residency clinic assessment and a practice system assessment (PSA). The authors designed the PSA to estimate the Physician Practice Connections (PPC) score, indicating the readiness of a practice to function as a patient-centered medical home (PCMH). Of 356 clinic directors or physician representatives responding to an initial inquiry, 221 completed the survey (62%)--representing 185 programs (49% of accredited programs). The majority of clinics were hospital based (139/220; 63%) or hospital supported (41/220; 19%) and were located in urban settings (151/217; 70%). Estimated payer mix categories included Medicare or managed Medicare (169; 29%), Medicaid or managed Medicaid (161; 34%), and self-pay (156; 25%). The mean estimated PPC score was 53 points (of 100; SD = 17.6). Suburban and rural clinics, Veterans Affairs' clinics, federally qualified health centers, and clinics with a higher proportion of patients with commercial insurance or managed Medicare earned higher scores. A substantial portion of residency clinics have elements needed for PCMH recognition. However, clinics struggled with connecting these elements with coordination-of-care processes, suggesting areas for improvement to support better functioning of ambulatory training practices.

The 4∶1 Schedule: A Novel Template for Internal Medicine Residencies

It is widely acknowledged that there is need for redesign of internal medicine training. Duty hour restrictions, an increasing focus on patient safety, the possibility of inadequate training in ambulatory care, and a growing shortage of primary care physicians are some factors that fuel this redesign movement. We implemented a 4∶1 scheduling template that alternates traditional 4-week rotations with week-long ambulatory blocks. Annually, this provides 10 blocks of traditional rotations without continuity clinic sessions and 10weeks of ambulatory experience without inpatient responsibilities. To ensure continuous resident presence in all areas, residents are divided into 5 groups, each staggered by 1week. We surveyed residents and faculty before and after the intervention, with questions focused on attitudes toward ambulatory medicine and training. We also conducted focus groups with independent groups of residents and faculty, designed to assess the benefits and drawbacks of the new scheduling template and to identify areas for future improvement. Overall, the scheduling template minimized the conflicts between inpatient and outpatient training, promoted a stronger emphasis on ambulatory education, allowed for focused practice during traditional rotations, and enhanced perceptions of team development. By creating an immersion experience in ambulatory training, the template allowed up to 180 continuity clinic sessions during 3years of training and provided improved educational continuity and continuity of patient care. Separating inpatient and ambulatory education allows for enhanced modeling of the evolving practice of internists and removes some of the conflict inherent in the present system.

The Neighborhood Health Exchange: Developing a Community Partnership in Residency

The current system of residency training focuses on the hospital setting, and resident exposure to the surrounding community is often limited. However, community interaction can play an important role in ambulatory training and in learning systems-based practice, a residency core competency. The goal of the Neighborhood Health Exchange was to develop a community partnership to provide internal medicine residents with an opportunity to interface with community members through a mutually beneficial educational experience. Internal medicine residents received training during their ambulatory block and participated in a voluntary field practicum designed to engage community members in discussions about their health. Community members participated in education sessions led by resident volunteers. Resident volunteers completed a survey on their experiences. All residents stated that the opportunity to lead an exchange was very useful to their overall residency training. Eight exchanges were held with a total of 61 community participants, who completed a 3-question survey following the session. This survey asked about the level of material, the helpfulness of the exchanges, and opportunities for improvement. We received 46 completed surveys from community members: 91% stated that the material was presented "at the right level" and 93% stated that the presentations were somewhat or very helpful. Eighty percent gave positive and encouraging comments about the exchange. Effective community partnerships involve assessing needs of the stakeholders, anticipating leadership turnover, and adapting the Neighborhood Health Exchange model to different groups. Community outreach can also enhance internal medicine ambulatory training experience, provide residents with patient counseling opportunities, and offer a novel method to enhance resident understanding of systems-based practice, especially within the larger community in which their patients live.

Ambulatory-Based Education in Internal Medicine: Current Organization and Implications for Transformation. Results of A National Survey of Resident Continuity Clinic Directors

Many have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide. We wished to describe the infrastructure and educational milieu at resident continuity clinics and assess clinic readiness to meet new IM-RRC requirements. National survey of ACGME accredited IM training programs. Directors of academic and community-based continuity clinics. Two hundred and twenty-one out of 365 (62%) of clinic directors representing 49% of training programs responded. Wide variation amongst continuity clinics in size, structure and educational organization exist. Clinics below the 25th percentile of total clinic sessions would not meet RRC-IM requirements for total number of clinic sessions. Only two thirds of clinics provided a longitudinal mentor. Forty-three percent of directors reported their trainees felt stressed in the clinic environment and 25% of clinic directors felt overwhelmed. The survey used self reported data and was not anonymous. A slight predominance of larger clinics and university based clinics responded. Data may not reflect changes to programs made since 2008. This national survey demonstrates that the continuity clinic experience varies widely across IM programs, with many sites not yet meeting new ACGME requirements. The combination of disadvantaged and ill patients with inadequately resourced clinics, stressed residents, and clinic directors suggests that many sites need substantial reorganization and institutional commitment.New paradigms, encouraged by ACGME requirement changes such as increased separation of inpatient and outpatient duties are needed to improve the continuity clinic experience.

Ambulatory Training Since Duty Hour Regulations: A Survey of Program Directors

Ambulatory Training Since Duty Hour Regulations: A Survey of Program Directors

Achieving the AAAs of Ambulatory Care: Aptitude, Appeal, and Appreciation

In the current health care environment more patient care has moved from in-hospital care to the ambulatory primary care settings; however, fewer internal medicine residents are pursuing primary care careers. Barriers to residents developing a sense of competency and enjoyment in ambulatory medicine include the complexity of practice-based systems, patients with multiple chronic diseases, and the limited time that residents spend in the outpatient setting. In an effort to accelerate residents' ambulatory care competence and enhance their satisfaction with ambulatory practice, we sought to change the learning environment. Interns were provided a series of intensive, focused, ambulatory training sessions prior to beginning their own continuity clinic sessions. The sessions were designed to enable them to work confidently and effectively in their continuity clinic from the beginning of the internship year, and it was hoped this would have a positive impact on their perception of the desirability of ambulatory practice. Improvement needs assessment after a performance, so we developed a structured, competency-based, multidisciplinary curriculum for initiation into ambulatory practice. The curriculum focused on systems-based practice, patient safety, quality improvement, and collaborative work while emphasizing the importance of continuity of care and long-term doctor-patient relationships. Direct observation of patient encounters was done by an attending physician to evaluate communication and physical examination skills. Systems of care commonly used in the clinic were demonstrated. Resources for practice-based learning were used. The immersion of interns in an intensive, hands-on experience using a structured ambulatory care orientation curriculum early in training may prepare the intern to be a successful provider and learner in the primary care ambulatory setting.

Patient attitudes to being treated by junior residents in the community

Objective Understanding the attitudes of patients to being treated by residents in the community. Methods A questionnaire was administered to patients visiting community family medicine teaching clinics. The study methodology included statements to which they agree or disagree. Results Three hundred and four questionnaires were completed by patients; 94% had visited a resident in the past year; 78.9% agreed that residents were as skilled as senior doctors, but only 45.4% felt that they were as quick at diagnosis as the senior doctors; 73.0% felt that residents spent more time with them; 40.0% were not pleased by the constant change of the residents attending on them. Analysis by logistic regression showed that men had a more positive attitude to the competence of the residents as well as their professionalism (OR 2.73, 95% CI, 1.45–5.10). Frequent visitors to the clinic had a more negative attitude to the residents’ professionalism (OR 0.91 (0.85–0.98)) and were more likely to agree with the statement “I would prefer to see the regular doctor and not a different resident each time” (OR 1.09 (1.01–1.18)). Those who were attended more by residents on their visits showed a positive attitude to the professionalism of residents (OR 1.14 (1.01–1.28)) and were less likely to agree with the statement “I would prefer to see the regular doctor and not a different resident each time” (OR 0.90 (0.84–0.98)). Conclusions Patients have a positive attitude to being treated by residents in ambulatory clinics, which is associated with repeat exposure to care by residents. Practical implications Departments with ambulatory training should consider having constant presence of residents in their teaching clinics, and teaching staff in the clinics should develop ways to recommend patients to be seen by residents.

Alternative Approaches to Ambulatory Training: Internal Medicine Residents’ and Program Directors’ Perspectives

Internal medicine ambulatory training redesign, including recommendations to increase ambulatory training, is a focus of national discussion. Residents' and program directors' perceptions about ambulatory training models are unknown. To describe internal medicine residents' and program directors' perceptions regarding ambulatory training duration, alternative ambulatory training models, and factors important for ambulatory education. National cohort study. Internal medicine residents (N = 14,941) and program directors (N = 222) who completed the 2007 Internal Medicine In-Training Examination (IM-ITE) Residents Questionnaire or Program Directors Survey, representing 389 US residency programs. A total of 58.4% of program directors and 43.7% of residents preferred one-third or more training time in outpatient settings. Resident preferences for one-third or more outpatient training increased with higher levels of training (48.3% PGY3), female sex (52.7%), primary care program enrollment (64.8%), and anticipated outpatient-focused career, such as geriatrics. Most program directors (77.3%) and residents (58.4%) preferred training models containing weekly clinic. Although residents and program directors reported problems with competing inpatient-outpatient responsibilities (74.9% and 88.1%, respectively) and felt that absence of conflict with inpatient responsibilities is important for good outpatient training (69.4% and 74.2%, respectively), only 41.6% of residents and 22.7% of program directors supported models eliminating ambulatory sessions during inpatient rotations. Residents' and program directors' preferences for outpatient training differ from recommendations for increased ambulatory training. Discordance was observed between reported problems with conflicting inpatient-outpatient responsibilities and preferences for models maintaining longitudinal clinic during inpatient rotations. Further study regarding benefits and barriers of ambulatory redesign is needed.

Incorporating Telehealth into Primary Care Resident Outpatient Training

Research is yet to fully examine the utility and effectiveness of telehealth in primary care resident ambulatory training. This study examined the attitudes of preceptors, residents, and nurses on (1) the impact of telehealth on healthcare; (2) the impact of telehealth on the work activity of resident clinics; (3) the impact of telehealth on resident training in the outpatient setting; and (4) the impact of telehealth on relationships. There were three focus groups, one each of preceptors (N = 5), residents (N = 10), nurses (N = 7). Eight focus group themes evolved regarding the use of telehealth in the resident clinic: (1) impact on patient/provider relationships; (2) consistent with the values of those using telehealth; (3) logistics; (4) reduces patient transfers; (5) appropriate level of care; (6) reimbursement concerns; (7) psychological risk; and (8) impact on resident/attending relationships. Though as yet not generalizable, results of this pilot study suggest that there is general acceptability of telehealth in ambulatory resident training settings, but there is concern about the impact that telehealth may have on relationships, logistics, finances, and the need to see patients face-to-face when there is greater complexity.

Feedback research in postgraduates on efficacy of education in school of medicine.

At the Medical School, Tirgu-Mures/Romania, in the Alumni Office of the Department of Social Medicine, two feed-back researches were performed in 1962 and 1973 on 100 graduates working in basic medical care, in order to evaluate the efficacy of practical medical training. Between 1962 and 1973 efforts have been made to bring the medical teaching nearer to the ambulatory practical training. The compulsory externship (4 to 6 years), the young students' work as nurses at the patients' beds (1 to 2 years), their distribution in rural factory surgeries (5 to 6 years), the night duties at medical emergency services (6 years), as well as their training in prophylactic medico-hygiene activities brought a lot of improvements to the practical training of the students, future general practitioners. However, there are problems in this field of hygiene and epidemiology, as well as in emergency assistance. The improvement of practical education goes on. The next feed-back research is planned for 1976.

Title VII Innovations in American Medical and Dental Education: Responding to 21st Century Priorities for the Health of the American Public

The Title VII Training in Primary Care Medicine and Dentistry grant program has been an engine for innovation by providing funds to develop and implement new curricula, new models of care delivery, and new methods of fellowship and faculty development. During period one, 1963-1975, the disciplines of family medicine and physicians assistants (PAs) first received funding to establish residency programs in family medicine and student training for PAs. Other innovations included interdisciplinary training and curricula in substance abuse and nutrition. During period two, 1976-1991, Title VII funds supported implementation of general dental residency programs. In family medicine, general internal medicine, and general pediatrics, ambulatory care training was expanded with a focus on community-oriented primary care and preventive medicine, as well as curricula in ethics, distance learning, behavioral health, and what is now called evidence-based medicine. During period two, Title VII also helped build the infrastructure of primary care through funding to recruit faculty, to expand training sites into community settings, and to incorporate topics relevant to primary care. During period three, 1992-present, innovations shifted to areas of clinical relevance or national priority, training in the care of vulnerable populations, and design of educational strategies to eliminate health disparities, often through collaborative partnerships between medicine, dentistry, and public health. This article focuses on three areas that reflect much of the current work of Title VII grantees: clinical skills and practice improvement, interdisciplinary models of training and patient care, and care of vulnerable and underserved populations.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Title VII and the Development and Promotion of National Initiatives in Training Primary Care Clinicians in the United States

The Title VII, Section 747 (Title VII) legislation, which authorizes the Training in Primary Care Medicine and Dentistry grant program, provides statutory authority to the Health Resources and Services Administration (HRSA) to award contracts and cooperative agreements aimed at enhancing the quality of primary care training in the United States.More than 35 contracts and cooperative agreements have been issued by HRSA with Title VII federal funds, most often to national organizations promoting the training of physician assistants and medical students and representing the primary care disciplines of family medicine, general internal medicine, and general pediatrics. These activities have influenced generalist medicine through three mechanisms: (1) building collaboration among the primary care disciplines and between primary care and specialty medicine, (2) strengthening primary care generally through national initiatives designed to develop and implement new models of primary care training, and (3) enhancing the quality of primary care training in specific disease areas determined to be of national importance.The most significant outcomes of the Title VII contracts awarded to national primary care organizations are increased collaboration and enhanced innovation in ambulatory training for students, residents, and faculty. Overall, generalist competencies and education in new content areas have been the distinguishing features of these initiatives. This effort has enhanced not only generalist training but also the general medical education of all students, including future specialists, because so much of the generalist competency agenda is germane to the general medical education mission.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.