What's New
Traditionally, training programs have followed a combination of both inpatient and outpatient duties on a weekly basis where continuity clinic is held in the midst of a ward week. This sometimes would create days known as “hell days” when a resident would have floor duties in the am, clinic in the pm, and then would have to return to long call duties in the evening. This would lead to high resident stress and in some cases dissatisfaction which would lead to suboptimal patient care. In the past, some ways to remedy this would be through schedule manipulations such as switching clinic, or switching long calls.
Ambulatory training is 2nd in priority to inpatient care. However, the irony is that although the majority of the training occurs in hospital, there is an expectation for excellence in the outpatient arena.
ACGME mandates that at least 33% of training should occur in the outpatient setting. The previous curriculum which is what is followed by most medicine training programs would barely meet this requirement by having 108 weekly continuity sessions over the 3 years and two blocks of weekly continuity clinic, ER, CBP, and subspecialty clinics during selectives and electives.
ACGME now has introduced a new regulation which takes effect in July 2009, which states the sponsoring institution must “assure models and schedules for ambulatory training that minimize conflicting inpatient and outpatient responsibilities” and “not place excessive reliance on residents to meet the service needs of the participating sites”. It also mandates that “At least 1/3 of the residency training must occur in the ambulatory setting – emergency medicine may count for no more than 2 weeks toward the required 1/3 ambulatory time” and faculty must supervise “longitudinal continuity experience in which residents develop a continuous, long-term therapeutic relationship with a panel of general internal medicine patients.”
To this end, we have created a new model to fulfill all of these goals and requirements and improve the educational experience for our housestaff. Instead of the traditional 2 months of ambulatory medicine blocks and weekly continuity care clinic, we now have scheduled six 2 week blocks of Ambulatory Care evenly spread throughout the year for each categorical resident. Basically, each resident will have two weeks ambulatory care, six weeks of other experiences, two weeks of ambulatory care, six weeks of other experiences, and so on. In these two week blocks, the houseofficer will participate in 3-4 continuity sessions, 2-3 subspecialty sessions, and a variety of didactics (Ambulatory Morning Report, Evidence-based medicine conference, Geriatrics conference). In addition, the resident is given protected time for self-directed learning through the completion of the Hopkins modules. With the addition of more than an extra month of ambulatory time over the year, the resident is now freed of clinic responsibility during most challenging inpatient rotations, such as the MICU, Memorial Sloan Kettering and nightfloat.