Traditional Internal Medicine Research Articles

Health care policy that relies on poor measurement is ineffective: Lessons from the hospital readmissions reduction program.

Health care policy that relies on poor measurement is ineffective: Lessons from the hospital readmissions reduction program.

Time Does Matter: Reduced Internal Medicine Clerkship Clinical Experiences Due to COVID-19.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has affected medical education in many ways.The Association of American Medical Colleges (AAMC) temporarily suspended clinical student rotations, calling for a transition to remote learning. Unfortunately, due to the heavy impact of COVID-19 in our South Florida community, medical students were not able to return to in-person activities for a significant time.During this period,students hadremote clerkship learning activities, didactic sessions, narrative projects, and small-group learning sessions, which were front-loaded using Zoom technology (Zoom Video Communications, Inc.,San Jose, California, United States) and web-based learning tools. Once in-person clinical experiences resumed, the duration of all third-year clerkships for the remainder of the year wasreduced to five weeks to allow for timely graduation.The Herbert Wertheim College of Medicine (HWCOM) Internal Medicine (IM) clerkshiphas traditionally beenan eight-week-long rotation.Other clerkships that varied from six to eight weeks were similarly reduced to five weeks.We hypothesized that the shortened duration of the IM clerkship would have negative impacts on National Board of Medical Examiners (NBME) exam performance and clerkship clinical experiences would likely be affected. Methods We compared the NBME subject exam results and end of clerkship evaluations from the Class of 2021 (CO2021) which had the traditional eight weeks of patient care, with the CO2022, which had only five weeks of in-person patient care.A T-test analysis was performed comparing performance on the NBME medicine clinical subject exam between students who completed the usual eight-week rotation versus those who completed a five-week rotation.We also evaluated the IM clerkship course evaluation and analyzed student responses and ratings to assess any areas that were statistically significant when comparing the traditional eight-week IM clerkship to the shortened five-week clerkship. Results There was no statistically significant difference (t=0.68,p<0.4951) in mean NBME subject exam performance between cohorts. Students who completed the shortened five-week IM clerkship indicated there waslimited volume and diversity of patients, which consequently affected their ability to complete all the required clinical experiences for the IM clerkship.These results indicated a statistically significant difference between the two cohorts (t =3.33, p<.001). Conclusion Students with shortened IM clerkship clinical care time (five weeks) were found to have no significant statistical differences in NBME subject exam performance compared to the traditional eight-week cohorts. However, students felt there was a decreased volume and diversity of patients, and they reported greater difficulties in completing the required clinical experiences, with diminished clinical confidence. Time does matter, and clinical time is very valuable for a student's undergraduate medical education.If another pandemic were to arise, the durationof differentclerkships should be carefully assessed and individualized, and methods to assess and reclaim lost clinical time during the advanced clinical and postgraduate years should be considered.

964. Impact of the COVID-19 Pandemic on Bedside Medical Education: A Mixed-Methods Study

BackgroundThe COVID-19 pandemic obligated academic medical programs to substantially alter the traditional Internal Medicine (IM) rounding model to decrease risk of inpatient nosocomial viral transmission. Our study aimed to describe how IM rounding practices changed during the COVID-19 pandemic and to understand the impacts of these changes on medical education. MethodsWe conducted a two-phase, mixed-methods study of inpatient IM rounding team practices at a large academic hospital in Houston, TX. In the first phase (January-February 2021), we organized and audio-recorded 4 virtual (Zoom) focus groups. Each included 5-6 rounding team members, divided by: attendings; senior residents; interns; and medical and physician assistant students. In the second phase (March-May 2021), we performed 6 direct observations of IM teams during rounds. Two observers systematically recorded variables such as time spent on non-bedside versus bedside rounds, number of each team member type entering patient rooms for bedside teaching, and types of personal protective equipment (PPE) worn. ResultsTopics discussed during focus groups included comparisons of rounding team size, rounding duration, physical distancing and PPE use, bedside education, communication methods, and patient safety before and after March 2020. Perceptions of changes in each topic were generally consistent across groups (Table 1). Direct observation data showed that team rounding styles remained diverse in the proportion of rounding time spent in an office versus on the wards, and in the number and types of team members entering patient rooms. IM team members uniformly wore respiratory PPE when entering all patient rooms; use of eye protection varied. Teams spent more total time discussing patients with or suspected to have COVID-19 compared to patients without COVID-19 (median 24 min versus 13 min, p< 0.0001). ConclusionOur results suggest that the COVID-19 pandemic adversely impacted bedside medical education, even into Spring of 2021. Conclusions from this study can be used to 1) address educational gaps related to COVID-19 pandemic-associated rounding changes and 2) create innovative methods of providing high-quality clinical education that will be minimally impacted by future respiratory virus pandemics.Disclosures Prathit A. Kulkarni, M.D., Vessel Health, Inc. (Grant/Research Support)

Clinical effect of minimally invasive aspiration and drainage of intracranial hematoma in the treatment of cerebral hemorrhage.

ABSTRACTObjectives:To explore the clinical value of minimally invasive aspiration and drainage of intracranial hematoma in the treatment of cerebral hemorrhage.Methods:Seventy-eight patients with cerebral hemorrhage who were treated in the Taian City Central Hospital and the Second Affiliated Hospital of Shandong First Medical University between June 2018 and December 2019 were selected. The patients were randomly numbered and divided into two groups by drawing lots, 39 in each group. The control group was treated with the traditional internal medicine conservative therapy, and the observation group was treated with minimally invasive intracranial hematoma aspiration and drainage. The indexes of the two groups were compared.Results:The efficacy rate of the observation group was significantly higher than that of the control group, and the difference was statistically significant (P<0.05). The National Institutes of Health Stroke Scale (NIHSS) score of the observation group was lower than that of the control group after treatment, and the difference was statistically significant (P<0.05). After treatment, the good recovery rate of the observation group was higher compared to the control group, and the difference had statistical significance (P<0.05). The incidence of complications in the observation group was lower than that of the control group, with a statistically significant difference (P<0.05).Conclusion:In the treatment of cerebral hemorrhage, minimally invasive intracranial hematoma aspiration and drainage facilitates the recovery of patients, promotes the improvement of neurological function, and has a high safety profile and an ideal prognostic quality.

Effect of an Immersive Primary Care Training Program on Educational and Clinical Outcomes in an Internal Medicine Residency Training Program: Meeting the Training Needs of a Modern-Day Physician Workforce.

Residents planning careers in primary care have unique training needs that are not addressed in traditional internal medicine training programs, where there is a focus on inpatient training. There are no evidence-based approaches for primary care training. Design and test the effect of a novel immersive primary care training program on educational and clinical outcomes. Nested intervention study. Twelve primary care residents, 86 of their categorical peers, and an 11-year historical cohort of 69 primary care trainees in a large urban internal medicine residency training program. Two 6-month blocks of primary care immersion alternating with two 6-month blocks of standard residency training during the second and third post-graduate years. Total amount of ambulatory and inpatient training time, subjective and objective educational outcomes, clinical performance on cancer screening, and chronic disease management outcomes. Participants in the intervention increased ambulatory training in both general medicine and specialty medicine and still met all ACGME training requirements. Residents reported improved subjective educational outcomes on a variety of chronic disease management topics and ambulatory care skills. They reported higher satisfaction with the amount of ambulatory training (4.3/5 vs. 3.6/5, p=0.008), attended more ambulatory clinics (242 vs. 154, p<0.001), and carried larger, more complicated panels (173 vs. 90 patients, p<0.001). They also performed better on diabetes management (86% vs. 76% control, p<0.001). Alumni who completed the intervention reported higher primary care career preparation (79% response rate) than those who did not (85% response rate) among an 11-year cohort of primary care alumni (4/5 vs. 3/5, p<0.001). A primary care training program that provides clinical immersion in the ambulatory setting improved educational outcomes for trainees and clinical outcomes for their patients. Providing more training in the ambulatory environment should be a priority in graduate medical education.

A novel approach to the program evaluation committee

BackgroundThe Accreditation Council for Graduate Medical Education requires each residency program to have a Program Evaluation Committee (PEC) but does not specify how the PEC should be designed. We sought to develop a PEC that promotes resident leadership and provides actionable feedback.MethodsParticipants were residents and faculty in the Traditional Internal Medicine residency program at Yale School of Medicine (YSM). One resident and one faculty member facilitated a 1-h structured group discussion to obtain resident feedback on each rotation. PEC co-facilitators summarized the feedback in written form, then met with faculty Firm Chiefs overseeing each rotation and with residency program leadership to discuss feedback and generate action plans. This PEC process was implemented in all inpatient and outpatient rotations over a 4-year period. Upon conclusion of the second and fourth years of the PEC initiative, surveys were sent to faculty Firm Chiefs to assess their perceptions regarding the utility of the PEC format in comparison to other, more traditional forms of programmatic feedback. PEC residents and faculty were also surveyed about their experiences as PEC participants.ResultsThe PEC process identified many common themes across inpatient and ambulatory rotations. Positives included a high caliber of teaching by faculty, highly diverse and educational patient care experiences, and a strong emphasis on interdisciplinary care. Areas for improvement included educational curricula on various rotations, interactions between medical and non-medical services, technological issues, and workflow problems. In survey assessments, PEC members viewed the PEC process as a rewarding mentorship experience that provided residents with an opportunity to engage in quality improvement and improve facilitation skills. Firm chiefs were more likely to review and make rotation changes in response to PEC feedback than to traditional written resident evaluations but preferred to receive both forms of feedback rather than either aloneConclusionsThe PEC process at YSM has transformed our program’s approach to feedback delivery by engaging residents in the feedback process and providing them with mentored quality improvement and leadership experiences while generating actionable feedback for program-wide change. This has led to PEC groups evaluating additional aspects of residency education.

The Application of the Mixed Teaching Mode of Core Curriculum in the Background of Information Technology

Purposes: Exploring the application of mixed teaching mode in the core course of Adult Nursing. Methods: Adult Nursing course was designed with the mixed teaching mode in the background of information technology, and applied to 51 students in the experimental class. After the course was finished, the online learning situation of the students was analyzed, and the results and evaluations of the course were compared with the control class. Results: The experimental class were significantly higher than those of the control class (t=2. 873, P=0. 006). Each item of students' evaluation of curriculum was significantly higher than that of control class (P&lt;0. 01). Conclusion: The application of mixed teaching mode in the background of information technology is an active impetus to the reform of educational idea, teacher's role, teaching method and teaching evaluation, which is of great practical significance to the reform of curriculum teaching. 'Supporting the modernization of our country with the modernization of education' is an important part of the education supply-side reform in China in, recent years, and the 'Internet' has been mentioned 8 times in the 19th CPC National Congress report. We should encourage all walks of life to accelerate the modernization drive by using internet technology and information technology. Educational Informationization has become the Research focus of current Education and Teaching Reform. 'Adult Nursing' is the core curriculum of nursing, which is set according to the international advanced 'life cycle' model (that is, the period of mother and child, children, adolescents, adulthood, old age and so on). General 128 class hours, dividing into the third or fourth semester, the content of the integration of traditional internal medicine, surgery, gynecology, infectious diseases, oncology, dermatology and ENT nursing. It covers a wide range of subjects and is difficult to learn, so students' general interest is not high. The mixed teaching mode, in a broad sense, refers to a strategy that synthetically applies different learning theories, different techniques and means, and different applications to implement teaching. At present, it mainly refers to the organic integration of two typical teaching forms: face-to-face classroom learning and online learning. The mixed teaching emphasizes on the application of appropriate technology to achieve the best teaching goal at the right time, which happen to have the same view with Bloom's idea and purpose of educational goal taxonomy[1]. In the course of Adult Nursing, our school tries to apply information technology to meet the needs of learners. With the help of computer platform and mobile phone app, combining traditional classroom teaching with online learning based on network to construct a mixed teaching mode[2], making the flipped classroom come true, and achieving better results, actively promoting the reform of education concepts and teacher's role, teaching methods and teaching evaluation. It is of great practical significance to the reform of curriculum teaching.

Implementation of a seven-day hospitalist program to improve the outcomes of the weekend admission: A retrospective before-after study in Taiwan.

ObjectivePatients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect.DesignA controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions.SettingA 2000-bed medical centre in TaiwanParticipantsHospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods.Main outcome measuresProportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality.ResultsThe pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared.ConclusionsThe seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development.

Commentaries on health services research

Commentaries on health services research

The exploration of PBL teaching on the subject of internal medicine of traditional Chinese medicine

To explore and discuss the teaching effect of problem-based learning (PBL) teaching method on the traditional Chinese medicine internal medicine. It emphasized that taking the student as the main body of teaching, and designing the situation for typical clinical medical records, which included stratifing the medical records, gradually releasing the records' information, guiding the students' divergent thinking, help students with the integration of the basic knowledge establish diagnosis and lastly offering the appropriate and rational treatment. It stimulated and interested the students with searching literature, giving positive thinking, and improving the exploration ability. The PBL showed a different view from the case discussion teaching method, and was proved to be a good teaching method for TCM internal medicine. Key words: Internal Medicine (TCM); Problem-based learning; Teaching methods

Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline.

Hospital medicine (HM) is rapidly evolving into new clinical and nonclinical roles. Traditional internal medicine (IM) residency training likely does not optimally prepare residents for success in HM. Hospital medicine residency training tracks may offer a preferred method for specialized HM education. Internet searches and professional networks were used to identify HM training tracks. Information was gathered from program websites and discussions with track directors. The 11 HM tracks at academic medical centers across the United States focus mostly on senior residents. Track structure and curricular content are determined largely by the structure and curricula of the IM residency programs in which they exist. Almost all tracks feature experiential quality improvement projects. Content on healthcare economics and value is common, and numerous track leaders report this content is expanding from HM tracks into entire residency programs. Tracks also provide opportunities for scholarship and professional development, such as workshops on abstract creation and job procurement skills. Almost all tracks include HM preceptorships as well as rotations within various disciplines of HM. HM residency training tracks focus largely on quality improvement, health care economics, and professional development. The structures and curricula of these tracks are tightly linked to opportunities within IM residency programs. As HM continues to evolve, these tracks likely will expand to bridge clinical and extra-clinical gaps between traditional IM training and contemporary HM practice. Journal of Hospital Medicine 2017;12:173-176.

Palliative Care Teaching in the Yale Internal Medicine Curriculum: How Are We Doing? (S710)

•Review the approach to curriculum mapping for current palliative care content in one Internal Medicine Residency Program.•Identify the resident level palliative care competencies that are explored and missed during Internal Medicine Training in this program.•Discuss the strengths and limitations of curriculum mapping as a method in this setting. As the prevalence of patients living with serious illness rises, it is essential that residents are trained to provide primary palliative care. To elucidate the existing palliative care exposure in the Yale Primary Care and Traditional Internal Medicine Residency Programs through the use of curricular mapping, a tool linking instructional methods with educational outcomes. To identify content gaps in the Yale Internal Medicine residencies based on published residency-level palliative care competency domains: Pain & Symptom Management (PSM), Communication, Psychosocial/Spiritual/Cultural Aspects of Care (PSC), Terminal Care & Bereavement (TCB), Palliative Care Principles & Practice (PCPP). We reviewed curricular content for 7/1/2014-6/30/2015. We identified core educational venues: grand rounds, morning report, attending rounds, ambulatory didactic sessions, noon conference, geriatrics rotation, electives, and the intranet palliative care curriculum. We reviewed the online content of grand rounds, ambulatory didactics, and the intranet curriculum. For morning report, attending rounds, and noon conference content, faculty from both residency programs were emailed. This was not feasible in the Traditional Program given scheduling complexity and size. We emailed 22 core Primary Care Program faculty for the title and learning Objectives identifying the covered competencies. We mapped the content to the competencies. We had data for 4 educational venues: grand rounds, morning report, attending rounds, ambulatory didactics. Of the physicians emailed 10 provided data. Within the 4 venues, 38 events addressed at least 1 competency domain. 66% addressed communication, 58% addressed PSC, 34% addressed PSM, 16% addressed PCPP, none addressed TCB. 10% were palliative care lectures, 10% covered Hospice, none covered Spirituality. Communication and Psychosocial & Cultural Aspects were addressed often while TCB and Spirituality were absent. Mapping was limited by a lack of a central content database and the inability to capture informal teaching.

Thermal dose t43 measured for commercial moxas

Sook-Hyun Lee1, Go Eun Lee2, Jung Sup Lee3, Kuem Ju Lee1, Sung Min Lim1, Hyun Choi1, Dong-A Kim4, Wan Ho Kim4, Chi Hyoung Son2 1 Department of Clinical Research for Rehabilitation, National Rehabilitation Research Institute 2 Department of Korean Traditional Rehabilitation Medicine, National Rehabilitation Hospital 3 Department of Korean Traditional Internal Medicine, National Rehabilitation Hospital 4 Department of Rehabilitation Medicine, Korean National Rehabilitation Hospital

Acupuncture therapy for treatment of diabetic peripheral neuropathy: a systematic review of randomized controlled trials

Sook-Hyun Lee1, Go Eun Lee2, Jung Sup Lee3, Kuem Ju Lee1, Sung Min Lim1, Hyun Choi1, Dong-A Kim4, Wan Ho Kim4, Chi Hyoung Son2 1 Department of Clinical Research for Rehabilitation, National Rehabilitation Research Institute 2 Department of Korean Traditional Rehabilitation Medicine, National Rehabilitation Hospital 3 Department of Korean Traditional Internal Medicine, National Rehabilitation Hospital 4 Department of Rehabilitation Medicine, Korean National Rehabilitation Hospital

An Evidence-Based Review of Hemiplegic Shoulder Pain

Sook-Hyun Lee1, Go Eun Lee2, Jung Sup Lee3, Kuem Ju Lee1, Sung Min Lim1, Hyun Choi1, Dong-A Kim4, Wan Ho Kim4, Chi Hyoung Son2 1 Department of Clinical Research for Rehabilitation, National Rehabilitation Research Institute 2 Department of Korean Traditional Rehabilitation Medicine, National Rehabilitation Hospital 3 Department of Korean Traditional Internal Medicine, National Rehabilitation Hospital 4 Department of Rehabilitation Medicine, Korean National Rehabilitation Hospital

Hospitalist workload and resident evaluations.

Most academic hospitalists fulfil the role of clinician educator and have many opportunities for the bedside clinical teaching of resident physicians; however, hospitalists are promoted at lower rates than traditional internal medicine faculty staff. The conflict between the demands of clinical productivity and time to teach may be central to understanding the lower rates of academic promotion seen in hospitalists. This investigation explores the relationship between clinical productivity and learner evaluations of hospitalist clinician educators. A retrospective review of clinical productivity and learner evaluations of hospitalists by residents was collected during the 2009-2012 academic years at Southern Illinois University School of Medicine. Correlation analysis between annual work relative value units (wRVUs), patient encounters and duty days with resident evaluations of faculty staff in the Accreditation Council for Graduate Medical Education core competencies was performed. Forty-one annual data sets, representing 18 individual hospitalists, were analysed. No significant correlations between clinical productivity, in terms of annual work RVUs, patient encounters and duty days, and resident learner evaluation scores was found. This investigation explores the relationship between clinical productivity and learner evaluations of hospitalist clinician educators This study found no significant influence of measures of annual clinical service workload on resident learner evaluations of hospitalist clinical educators. These results are consistent with data reported for emergency medicine doctors and anaesthesiologists. These results may have significant implications for the staffing requirements for academic hospitalists.

Combat internist: the internal medicine experience in a combat hospital in Afghanistan.

Military internists and internal medicine subspecialists are physicians who generally work in traditional internal medicine settings. However, when deployed to combat settings, they must prepare and adapt their skills for a wide spectrum of complex, polytrauma, and multinational patients. There are limitations in personnel, equipment, and technical resources that make the circumstances complex and demanding. This article highlights some of the unique roles, challenges, and experiences of four military internists at the NATO Role 3, a deployed combat hospital in Afghanistan.

Application of problem-based learning method in the internal medical teaching of TCM

Objective To explore the effect of problem-based learning method in traditional Chinese internal medicine teaching. Methods 58 students enrolled in the major of integrated traditional Chinese and western medicine in class C at the Beijing University of Chinese medicine were arranged to receive PBL（test group）or traditional teaching methods（control group）in 2 courses and complete 116 questionnaires. The teaching outcomes were evaluated by questionnaire and individual interviews. Results Compared with controls,students receiving PBL performed significantly better in terms of active classroom atmosphere, broadening their knowledge, and improving teamwork ability（χ2 were 7.16, 4.07, 4.09, P〈0.05）. Conclusion The PBL strategy has the advantage than the traditional teaching methods in traditional Chinese internal medicine teaching. Key words: PBL; Traditional Chinese internal medicine; Teaching methods

Does implementation of a hospitalist program in a Canadian community hospital improve measures of quality of care and utilization? an observational comparative analysis of hospitalists vs. traditional care providers

BackgroundDespite the growth of hospitalist programs in Canada, little is known about their effectiveness for improving quality of care and use of scarce healthcare resources. The objective of this study is to compare measures of cost and quality of care (in-hospital mortality, 30-day same-facility readmission, and length of stay) of hospitalists vs. traditional physician providers in a large Canadian community hospital setting.MethodsWe performed a retrospective analysis of data from the Canadian Institute for Health Information (CIHI) Discharge Database, using multivariate logistic and linear regression analyses comparing performance of four provider groups of traditional family physicians (FPs), traditional internal medicine subspecialists (other-IM), family physician-trained hospitalists (FP-Hospitalist), and general internal medicine-trained hospitalists (GIM-Hospitalist).ResultsCompared to traditional FPs, FP-Hospitalists and GIM-Hospitalists demonstrate lower mortality [OR 0.881, (CI 0.779 – 0.996); and OR 0.355, (CI 0.288 – 0.436)] and readmission rates [OR 0.766, (CI 0.678 – 0.867); and OR 0.800, (CI 0.675 – 0.948)]. Compared to traditional FPs, GIM-Hospitalists appear to improve length of stay [OR−2.975, (CI −3.302 – -2.647)] while FP-Hospitalists perform similarly [OR 0.096, (CI −0.136 – 0.329)]. Compared to other-IM, GIM-Hospitalists have similar performance on all measures while FP-Hospitalists show a mixed impact.ConclusionsCompared to traditional family physicians, hospitalists appear to improve measures of quality and resource utilization. Specifically, hospitalists demonstrate lower in-hospital mortality and 30-day readmission rates while improving (or at least showing similar) length of stay. Compared to traditional subspecialists, hospitalists demonstrate similar performance despite looking after sicker and more complex medical patients.

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.