Continuity Clinic Experience Research Articles

Development of The Johns Hopkins University School of Nursing Adult/Geriatric Primary Care Nurse Practitioner Program in HIV Prevention, Treatment, and Care

In response to the call to create an AIDS Education and Training Center for Nurse Practitioner Education by the Health Resources and Services Administration, The Johns Hopkins University School of Nursing embarked on a transformative curriculum overhaul to integrate HIV prevention, treatment, and care into the Adult/Geriatric Nurse Practitioner Program. A six-step process outlined in the Curriculum Development for Medical Education was followed. A pilot cohort of Adult/Geriatric Nurse Practitioner students were enrolled, including 50% primary care setting and 50% HIV-focused primary care through a 12-month HIV continuity clinic experience. Through this pilot, substantive changes to the program were adopted. Programmatic outcomes were not compromised with the modification in clinical hours. The model of a 12-month HIV continuity clinical experience reduced the number of required preceptors. This model has important implications for the HIV workforce by demonstrating successful integration of HIV and primary care training for nurse practitioners.

Effect of Resident Communication to Clinic Schedulers on Continuity in Pediatric Continuity Clinic

The ACGME requires pediatric residency programs provide a continuity clinic experience. There are a number of barriers to maintaining continuity during residency training including resident service obligations and duty hour restrictions. Lack of continuity creates dissatisfaction among residents both within our program and nationwide. The purpose of this study is to determine if resident communication with clinic schedulers increases the level of continuity for residents during their continuity clinic experience.

147: Pediatric Residents' Continuity Clinic: An Evaluation Survey

Training in ambulatory care and continuity of care has become an integral part of residency programs. Continuity clinics attempt to address these challenging aspects of medical education. Our centre has a long-standing paediatric residents' continuity clinic (PRCC) that had never been formally evaluated. To assess resident satisfaction of their continuity clinic experience, before and after evidence-based improvements were made. Cross-sectional surveys were conducted at a single paediatric training site in the academic years of 2012–2013 and 2013–2014 using online questionnaires. Our ethics committee approved this study. Most eligible residents participated in both questionnaires, of which around 60% had a high probability of becoming a general paediatrician. Residents had one monthly clinic; half the residents would increase this frequency. The majority had a mean of three to four appointments per session and in general they thought this was just enough. Before the study, 37% of residents were using standardised general follow-up tools, and 7% were using developmental screening tools. These figures only slightly improved at the time of the second questionnaire (48% and 8%). This is in the process of being formally addressed. Complex patients were perceived as being a difficult population to attend to within the settings of the PRCC, yet more than half the residents (55%) wished to see a greater number of complex patients. To attempt to facilitate this, PRCC patients became eligible to care coordination in our medical home program. Perception of teaching seemed to greatly improve during the study, becoming more consistent amongst preceptors. Teachers were generally perceived as being more enthusiastic and better acquainted with the resident following changes in the clinic's schedule. Evaluation was drastically improved; at the beginning of the study, one resident out of two had never been evaluated and 80% had never experienced direct observation of their ambulatory performance. In 2013–2014, the majority of residents had been evaluated (84%) and directly observed (56%). General resident satisfaction was also significantly enhanced; no resident said to be unsatisfied with the experience in the second questionnaire as opposed to 26% in the first. The overwhelming majority of residents agree that the continuity clinic is important in their training and for their future career. Residents highly value the continuity clinic educational experience; satisfaction markedly increased after improvements were made. These findings reiterate the importance of the continuity clinic model and the need for constant appraisal of this fundamental teaching opportunity.

Creating an educationally minded schedule: one approach to minimize the impact of duty hour standards on intern continuity clinic experience.

To determine if implementing an educationally minded schedule utilizing consecutive night shifts can moderate the impact of the 2011 duty hour standards on education and patient continuity of care in longitudinal primary care experience (continuity clinic). A 14-month pre–post study was performed in continuity clinic with one supervising physician group and two intern groups. Surveys to assess attitudes and education were distributed to the supervising physicians and interns before and after the changes in duty hour standards. Intern groups’ schedules were reviewed for the number of regular and alternative day clinic (i.e. primary care experience on a different weekday) sessions and patient continuity of care. Fifteen supervising physicians and 51 interns participated (25 in 2011, 26 in 2012). Intern groups’ comfort when discussing patient issues, educational needs and teamwork perception did not differ. Supervising physicians’ understanding of learning needs and provision of feedback did not differ between groups. Supervising physicians indicated a greater ability to provide feedback and understand learning needs during regular continuity clinic sessions compared with alternative day clinics (all p < 0.05). No significant difference was detected between intern groups in the number of regularly scheduled continuity clinics, alternative day clinics or patient continuity of care. The 2011 duty hour standards required significant alterations to intern schedules, but educationally minded scheduling limited impact on education and patient continuity in care.

Resident Education in Free Clinics: An Internal Medicine Continuity Clinic Experience

Most internal medicine (IM) residency programs provide ambulatory training in academic medical centers. Community-based ambulatory training has been suggested to improve ambulatory and primary care education. Free clinics offer another potential training setting, but there have been few reports about the experience of IM residents in free clinics. We assessed the feasibility and acceptability of inclusion of an ambulatory rotation in a free clinic and IM residency curriculum and the advantages of the free clinic setting over the traditional ambulatory clinic model. In 2010, the University of Chicago Internal Medicine Residency Program partnered with a free clinic in order to establish a community-based continuity clinic experience. To assess the feasibility of this innovation, 16 residents were surveyed 9months after implementation of the clinic to determine satisfaction, perceived preparation to address common medical conditions, and attitudes toward the underserved care population. A subset of these responses was compared to responses from residents in the traditional clinic model. Residents in the free clinic rotation were more satisfied and perceived they were more prepared to work in low-resource settings and reported similar levels of preparation regarding common outpatient conditions than residents in a traditional continuity clinic format. They reported increased future likelihood of working in an underserved clinic. Our exploratory study suggests free clinics may be an effective platform for community-based continuity clinic training.

Ambulatory Education Redesign: Time to Get Inspired

Ambulatory Education Redesign: Time to Get Inspired

The JGIM 2013 Medical Education Theme Issue: A Study in Diversity

On behalf of the JGIM editorial team, welcome to JGIM’s 2013 Medical Education Theme Issue! The editors were delighted to receive nearly 150 submissions to this special issue, many of them of very high quality. Narrowing this field to the articles selected for the current issue was not an easy task, and I must acknowledge the massive efforts of each of the Deputy Editors who worked on this issue. In addition, this volume of submissions necessitated significant contributions from many peer reviewers, without whose careful and timely manuscript evaluations this issue could not have taken shape. Most if not all of these individuals are members of the Society for General Internal Medicine, so this issue is truly an SGIM achievement. So what does this issue offer you, the reader? My comments will be brief, since the best way to enjoy this set of articles will be to dive right into it. In short, this issue offers a diverse overview of many of the key issues in medical education today. A quick scan of the titles of these articles illustrates this diversity, and what follows is a walking tour. There are several articles on ambulatory care training, including studies of the feasibility of new ambulatory care models and the role of satisfaction with continuity clinic experiences in career decisions. Of course, changes in medical education are not limited to the outpatient environment. Inpatient changes and issues related more broadly to duty hour regulation are evident in the analyses of how interns spend their time in the hospital and the relationship between patient contact and medical knowledge. As the practice of medicine evolves, medical education must also evolve. These articles demonstrate how this change can be studied. They also demonstrate the importance of attention to the interconnections between curriculum and the profession. This issue also contains a collection of contributions on different aspects of care transitions, a topic of much current discussion in medical education at all levels of training. There is no question that duty hour regulation has increased the importance of effective care transitions and “hand-offs” for patient safety and as educational opportunities themselves. These articles challenge us to re-evaluate how (and how early) we should train learners on these key skills, how we can best assess competency in them, and the importance of including the patient perspective as improvements are considered. Duty hour regulations have led to less fatigue among learners, but positive impacts on patient safety and learner distress have been less clear. The study on patient mortality trends in the era of duty hour reform adds some reassurance that patient safety may not have been adversely affected by these regulations, but also makes it clear that more study is needed to better understand the full scope of the effects of these reforms. In addition, the disturbing trends on substance misuse by medical students suggest we must do a better job of supporting learners in our current education environments. Of course, the experiences of educational leaders are also important. To this end, the report on the well-being of program directors in internal medicine offers some favorable data on how well this group of educational administrators and leaders cope with their demanding work roles. In addition to the diversity of topics contained within this set of articles, there is a diversity of study designs, including innovative pilot studies, national surveys, randomized controlled trials, and systematic reviews. The contributing authors and institutions are also diverse, with representation of both traditional academic medical centers and community-based institutions. These topics and contributors demonstrate the broad interests and expertise current medical educators possess. Although the articles in this issue cannot definitively provide the answers to the issues facing modern medical education, they do offer great hope for the future of medical education. It is gratifying to see that so many bright scholars are studying the best ways forward. The JGIM editors hope you enjoy reading these articles. We also hope you will each take up the challenge to join these authors in helping medical education continue to advance to its fullest potential.

The paradoxical influence of resident continuity clinic on primary care.

Enhancing access to primary care is the focus of much national debate. With health care reform imminent, our country is facing a shortage of physicians, particularly primary care physicians to serve a growing population of individuals with health care coverage. As an internal medicine (IM) residency program director, I find myself wondering if the traditional continuity clinic experience draws residents toward, or away from, a career in primary care. If we are to meet society's needs, we must consider better ways to engage our future physicians in primary care. Medical schools are exploring ways to use their recent enrollment expansion for the public good.1 Interventions being considered to increase the number of medical students with an interest in primary care include changing admission qualifications, reforming the curriculum, and expanding clinical sites to community settings, rural sites, and students' home communities.2 These approaches are important, but the effort cannot be limited to interventions at the undergraduate medical education level. We must be mindful of the factors and experiences that influence residents' career choices. The conflict many residents experience between required inpatient and outpatient duties, specifically the timing of continuity clinic, may paradoxically be driving residents away from a career in primary care. Traditional IM residency continuity clinic is one-half day sessions weekly throughout training. The Accreditation Council for Graduate Medical Education requirements for continuity clinic are complex.3 Requirements include scheduling that minimizes conflicts between inpatient and ambulatory experiences, yet this requires residents to manage their continuity patients interspersed between other ambulatory patient visits. In addition to acquiring the knowledge and skills for ambulatory care, developing longitudinal relationships with patients, and learning unique systems-based processes, residents must receive evaluation of their performance data for their chronic disease management and preventive care, and develop a data-based action plan. All of this must occur in at least 130 sessions, over 30 months of training, and it may not be interrupted by more than one month, with residents expected to concurrently participate in inpatient, intensive care, and other clinical rotations. This makes it challenging to ensure compliance, especially given the limits on resident duty hours.4 As a primary care physician who supervises residents on inpatient wards, I empathize with my residents' struggles to balance inpatient and ambulatory care responsibilities. When I am assigned inpatient duties, I find it challenging to devote adequate time to my clinic. Although I am passionate about primary care and have a strong administrative support system, clinic can feel burdensome during these busy times. If we wish to engage residents in primary care, we must restructure the traditional model. This should do more than minimize inpatient and outpatient duties; we must separate them. Innovative programs have developed schedules that successfully do this, alternating “blocks” of inpatient time with clinic time, with weekly intervals (4∶1 or other ratios) or 6 to 12 consecutive months of clinic.5 At our institution, we are planning to alternate clinics every other month with a practice partnership model, such that patients are assigned to a resident pair. Creating schedules that accommodate unique institutional structures deserves strong consideration. By restructuring traditional continuity clinic to decrease the tension from inpatient and outpatient duties, we may find residents enjoy spending time in clinic and are receptive to the rewards of a career in primary care.

Educating Generalists: Factors of Resident Continuity Clinic Associated With Perceived Impact on Choosing a Generalist Career

Fewer residents are choosing general internal medicine (GIM) careers, and their choice 5 be influenced by the continuity clinic experience during residency. We sought to explore the relationship between resident satisfaction with the continuity clinic experience and expressed interest in pursuing a GIM career. We surveyed internal medicine residents by using the Veterans Health Administration Office of Academic Affiliations Learners' Perceptions Survey-a 76-item instrument with established reliability and validity that measures satisfaction with faculty interactions, and learning, working, clinical, and physical environments, and personal experience. We identified 15 reliable subscales within the survey and asked participants whether their experience would prompt them to consider future employment opportunities in GIM. We examined the association between satisfaction measures and future GIM interest with 1-way analyses of variance followed by Student-Newman-Keuls post hoc tests. Of 217 residents, 90 (41%) completed the survey. Residents felt continuity clinic influenced career choice, with 22% more likely to choose a GIM career and 43% less likely. Those more likely to choose a GIM career had higher satisfaction with the learning (P = .001) and clinical (P = .002) environments and personal experience (P < .001). They also had higher satisfaction with learning processes (P = .002), patient diversity (P < .001), coordination of care (P = .009), workflow (P = .001), professional/personal satisfaction (P < .001), and work/life balance (P < .001). The continuity clinic experience 5 influence residents' GIM career choice. Residents who indicate they are more likely to pursue GIM based on that clinical experience have higher levels of satisfaction. Further prospective data are needed to assess if changes in continuity clinic toward these particular factors can enhance career choice.

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.

Continuity of Care in Fixed-Day Versus Variable-Day Resident Continuity Clinics

Since the introduction of resident work-hour standards, pediatric residency programs have struggled to preserve robust continuity clinic experiences. Many programs have resorted to more flexible approaches to resident scheduling. We know little regarding the impact of such changes. We compared 2 continuity clinic scheduling models: a traditional fixed-day clinic and a variable-day clinic in which resident clinic days vary each week to accommodate resident schedules. The setting for our study was a large university resident continuity clinic. We analyzed 111 resident schedules and 1113 visits by children aged younger than 1 year during 2 periods: July 2007 to December 2007, when residents were scheduled by using a variable-day clinic model, and July 2008 to December 2008, when a fixed-day model was used. We compared the number of clinic sessions per resident and continuity of care. We used the usual provider of care definition of continuity: the proportion of visits in which a patient is seen by his or her primary resident. A multivariable logistic regression was used to model the relationship between patient continuity of care and clinic structure (fixed-day vs variable-day), resident level, patient age, and appointment type. The number of clinics per resident during a 6-month period was higher using variable-day scheduling (19.6 vs 16.2; P < .01), whereas continuity of care was lower (0.54 vs 0.61; P = .01) In the multivariate model, continuity of care was significantly higher under the fixed-day model (odds ratio 1.40; P < .01). Scheduling residents for continuity clinic on variable days results in lower patient continuity of care despite increased resident time in clinic.

Adolescent Medicine Training in Pediatric Residency Programs

The aim of this study was to provide an assessment of pediatric residency training in adolescent medicine. We conducted 2 national surveys: 1 of pediatric residency program directors and the other of faculty who are responsible for the adolescent medicine block rotation for pediatric residents to elicit descriptive and qualitative information concerning the nature of residents' ambulatory care training experience in adolescent medicine and the workforce issues that affect the experience. Required adolescent medicine topics that are well covered pertain to normal development, interviewing, and sexual issues. Those least well covered concern the effects of violence, motor vehicle safety, sports medicine, and chronic illness. Shortages of adolescent medicine specialists, addictions counselors, psychiatrists, and other health professionals who are knowledgeable about adolescents frequently limit pediatric residency training in adolescent medicine. Considerable variation exists in the timing of the mandatory adolescent medicine block rotation, the clinic sites used for ambulatory care training, and the range of services offered at the predominant training sites. In addition, residents' continuity clinic experience often does not include adolescent patients; thus, pediatric residents do not have opportunities to establish ongoing therapeutic relationships with adolescents over time. Both program and rotation directors had similar opinions about adolescent medicine training. Significant variation and gaps exist in adolescent medicine ambulatory care training in pediatric residency programs throughout the United States. For addressing the shortcomings in many programs, the quality of the block rotation should be improved and efforts should be made to teach adolescent medicine in continuity, general pediatric, and specialty clinics. In addition, renewed attention should be given to articulating the core competencies needed to care for adolescents.

Community Discernment: Getting Nonprocedural Documentation Right—A First Step to Exemplary Accreditation

Although the Graduate Medical Educational community has had much experience with procedural case logs, they have had little with nonprocedural case logs. Practical experiences are at the heart of physician development. It is important for residents to reflect on their experiences, for program directors to understand the range of experiences actually achieved by each of their residents, and for regulators including both the residency review committee and the boards to have information to determine whether programs and residents meet standards for accreditation and certification. Although some of the lessons learned from procedural case logs will be helpful in determining how best to implement nonprocedural case logs, in general, new ground is being broken. An opportunity exists for the graduate medical education community to engage in a series of clarifying conversations about how to best capture the authentic experiences of residents and how to use the information to promote improvement. Conditions that will help the community discern the best path forward include: clarity of purpose, commonly agreed-upon principles, and the creation of a reliable structure for communication and feedback—a structure that enables trust and improvement. On June 22, 2006, representatives of the Association of Program Directors in Pediatrics (APPD), the Pediatric Residency Review Committee (RRC), and the Accreditation Council for Graduate Medical Education (ACGME) met to have a conversation about how best to proceed with the implementation of the nonprocedural case logs focused on capturing the continuity clinic experience. ACGME’s new mission, vision, values, and strategic priorities guided its perspective. ACGME’s mission is to improve health care by assessing and advancing the quality of resident physicians’ education through accreditation. Its vision is exemplary education. Its values are accountability, excellence, and professionalism. These values constitute principles that could guide ongoing dialogue. By accountability, ACGME requires that its processes are open and transparent; that it is responsive to both the educational community and the health of the public; and that its results are reliable, valid, and consistent. By excellence, it means accreditation that is efficient and effective, outcomes-based, improvement oriented, and innovative. By professionalism, ACGME means that its actions are respectful and collaborative, responsive, ethical, and fair. The ACGME recently completed a self-study that in

UNDERSTANDING RESIDENT CONCERNS WITH AMBULATORY CARE EXPERIENCES IN TRAINING.

Purpose Internal medicine residents have been increasingly choosing subspecialty careers over those in general internal medicine. Resident evaluations of the ambulatory general internal medicine training have been consistently decreasing. Ambulatory internal medicine has become complicated across all practice settings, academic to private practice. The office microsystem has become a target for meaningful primary care change. We conducted resident focus groups to discuss ambulatory experiences during training. Methods All residents were invited to participate in one of three focus groups over the standard noon conference time. Thirty-nine (43%) residents participated. Three sessions were held, one for each level of training: postgraduate year (PGY) 1, 2, and 3 or higher, with similar numbers participating in each session. Resident comments were elicited on the topics of dislikes with the ambulatory experience, educational benefit of both continuity clinic and ambulatory care block experiences, types of patients cared for in the clinic, learning needs, and the ideal resident clinic. Results The primary themes that emerged from the focus groups included patient scheduling, medical records, clinic organization, system-based care, patient characteristics, resident expectations of attendings and vice versa, and resident education, including didactics, evaluation, and areas in which residents lack confidence due to lack of sufficient exposure. These limited-exposure areas included prevention, office procedures, dermatology, sports medicine/orthopedics, business of medicine and billing, time management, and researching clinical questions in an office setting. Overall, these themes and concerns were consistent across all levels of training. Conclusions Internal medicine residents have traditionally felt that residency culture is inpatient-centric and therefore voiced concerns spanning all areas of their ambulatory education. The resultant themes from our focus groups parallel those concerns plaguing most internal medicine practices, academic to private practice. With this knowledge, ambulatory education can change to meet residents perceived needs, improve confidence with general internal medicine knowledge and skills, and potentially result in higher percentages of residents choosing a career in general internal medicine. We are tailoring the ambulatory experiences in our residency program to include changes based on our residents9 concerns.

Validation of a Scoring System to Evaluate Performance of a Hemi-Thyroidectomy

Objective.—To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting.Method.—Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs.Results.—Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents.Conclusions.—Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.

Changes in Pediatric Residents' Perceptions of Their Continuity Experience During Their Training: A National Study

To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting. Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs. Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents. Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.

Obstetrics and Gynecology Resident Satisfaction With an Integrated, Comprehensive Abortion Rotation

To evaluate obstetrics and gynecology resident satisfaction with a comprehensive, integrated abortion rotation. The University of California, San Francisco obstetrics and gynecology residency program includes a 6-week PGY-3 family planning rotation at an in-hospital clinic where abortions are provided up to 23 weeks of gestation. Residents annually evaluate the educational value of all clinical rotations on a 5-point Likert scale, with 5 indicating "maximum value," and 1 "no value." Using data from 1998-2003, we compared ratings of the family planning rotation with all other PGY-3 rotations. We also surveyed residents 1 to 3 years after graduation to assess the rotation qualitatively and quantitatively. Forty residents completed the abortion training, none opted out of training, and all completed the evaluations. Of all rotations in the third year, the family planning rotation was the highest rated (4.70), was similar in value to a high-volume surgical rotation (4.51, P > .10) and the elective rotation (4.45, P >.05), and surpassed the average score for all inpatient rotations (4.00, P < .001), continuity clinic (4.10, P < .001), and outpatient clinical experiences (4.06, P <.01). According to residency graduates, the family planning rotation was rated 4.8 (where 5 indicates "far greater value" than other rotations), and 85% of respondents rated it of "maximum learning value". Obstetrics and gynecology residents place high value in the University of California, San Francisco PGY-3 family planning rotation during their training and in their first years of practice.

Closing the gap between internal medicine training and practice: Recommendations from recent graduates

Closing the gap between internal medicine training and practice: Recommendations from recent graduates

Use of an Electronic Medical Record to Profile the Continuity Clinic Experiences of Primary Care Residents

To assess the variation in outpatient educational experiences among residents in a primary care internal medicine residency program. The authors conducted an observational study within a primary care residency program in Boston, Massachusetts, involving eight primary care residents in 2001-02. A data management system was created that uses information on clinical experiences collected from an electronic medical record (EMR). The EMR records clinical information from patient encounters in resident continuity clinics, including patient demographics and diagnostic codes entered by the residents. Primary and secondary diagnosis from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) were assigned to clinical categories (e.g., cardiology, orthopedics) and these assignments were programmed into a spreadsheet that could take the diagnostic data directly from the EMR downloads and produce reports using only the primary diagnosis, using all diagnoses, or using the assigned clinical categories. The EMR download showed 2,468 patient encounters for the eight residents in the primary care program. The most common clinical encounters were for health maintenance (17%), cardiology (14%), and women's health (10%). In contrast, rheumatology (0.5%) and hematology/oncology (2%) encounters were less frequent. There were substantial variations among residents in terms of distribution of encounter diagnoses, and the age and gender of patients seen in continuity clinic. Abstracting data from an EMR represents a feasible method for assessing programmatic and individual learner experiences in the outpatient setting. Such information may help target curricular adjustments to ensure an appropriate diversity and depth of clinical training.

Care to underserved children: Residents' attitudes and experiences.

To examine: 1) the relationship between residents' responses toward caring for underserved children and families during residency and their perceptions of their continuity clinic experience; and 2) which characteristics are related to continuing to care for the underserved after completion of training. Cross-sectional descriptive study. A 49-item questionnaire was mailed to 210 third-year pediatric residents at 12 urban training programs in the Northeast in May 1995. Information was collected about residents' emotional responses toward caring for underserved families, their assessments of clinic operations, their sense of effectiveness in caring for underserved patients in continuity clinic, preresidency experiences with the underserved, and their intent to care for the underserved after training. Of 210 surveys mailed, 71% were returned. Thirty-six percent of residents planned to pursue a career in primary care, 53% did not, and 11% did not answer or were planning a year as chief resident. Fifty-seven percent of all residents planned to devote a portion of their practice toward caring for the underserved after training. Residents whose emotional responses toward caring for the underserved included: 1) not worrying that they had become numb to children's psychosocial difficulties, 2) not feeling angry with how families cared for their children, and 3) feeling more empathy with the underserved had significantly higher mean scores on both their assessment of clinic operations and their sense of effectiveness. The only demographic characteristic associated with a greater sense of effectiveness was being black. To better characterize which residents planned to care for the underserved after training, we examined a subsample of 46 residents who recalled an interest in caring for the underserved during residency training and who were pursuing a career in primary care. Residents that did not recall an interest in caring for the underserved at the onset of residency training were unlikely to have plans to care for the underserved after the completion of training. Within this group residents who planned to care for the underserved after training differed significantly from residents who did not plan to continue this work by feeling a greater sense of effectiveness in clinic, feeling less worried about becoming numb, and having greater empathy for underserved families. There are a number of identifiable emotional responses residents develop toward caring for the underserved that relate to their perceptions of continuity clinic and whether a resident chooses to continue to care for the underserved after training.