Abstract

To the Editor:

Recent years have witnessed an increasing trend towards reforming and redesigning the configuration of internal medicine residency training to prepare the residents for future clinical practice.^1,2 This has meant a step-by-step increase in the number of resident clinic sessions and the percentage of time spent in outpatient settings for meeting accreditation requirements. Increased exposure without a well thought out infrastructure may, however, prove counterproductive.

A major bulk of preventive and diagnostic medicine is practiced in the outpatient clinics, which lends an ideal educational model for residents to provide high-quality, cost-effective patient care under the supervision of faculty members. However, residency programs are more often than not designed around the needs and requirements of recruiting institutions. Resident clinics are frequently understaffed with limited access to information technology. Coexisting inpatient responsibilities add to the burden, which limits the excitement that a well-rounded outpatient exposure is supposed to provide.

In a study exploring ambulatory care experience at the Johns Hopkins School of Medicine,³ resident ratings were highest on diversity of illness seen, medical record systems used, and contact with preceptors who were receptive to questions. On multivariate analysis, high ratings of preceptors as role models were most strongly associated with valuing clinic (corrected relative risk 3.44). Another study⁴ demonstrated that patients with extremes of age, female sex, less education, Medicare and Medicaid insurance, increased number of chronic conditions and medications, number of visits to the practice, and worse self-reported health status placed higher value on continuity of care.

Conflicting arguments on the significance of continuity of care can stem from variability in its importance to different patient subsets. A substantial percentage of patients seen in university outpatient clinics have multiple, complex, inter-related medical and psychological problems that are compounded by the social and financial burdens that they face. These patients may need urgent appointments and more frequent follow-ups, suggesting a need for patient-stratification and improved coverage while the resident physician is not available. Inability to secure a much-needed appointment and/or inability to get a prescription refill in time are some examples of how patient satisfaction can suffer in such an environment. A solution could be the use of hospitalists and midlevel practitioners in the healthcare team including resident clinics. However, in the era of tumbling economy and plunging revenues, resources available for primary care clinics may be scarce and implementation of such policies may prove difficult. Time spent in such a chaotic, disorganized environment of an outpatient clinic could be a major deterrent, preventing residents from pursuing a career in internal medicine.

These are hefty challenges and present themselves with plenty of questions for administrators and program directors; however, there are no easy answers. It would be a great beginning if a subgroup of clinical faculty could be provided protected time and incentives to develop learning tools and to evaluate, supervise, and teach residents. This should be accompanied by the presence of ‘core faculty’ members who work with residents longitudinally and a well-balanced curriculum addressing clinical and nonclinical topics related to patient care. Incorporation of these changes could be the first major step towards enhanced ambulatory training.

A 21^st century internal medicine resident should be well prepared to care for patients who may have complex needs, by practicing evidence-based medicine, equipped with the latest in information technology.