TABLE 2: Survey Results by Ambulatory Training Site N=78
Survey Item / PCMH (n=45)N (% yes) or mean (SD)
/ HBC (n=18)
N (% yes) or mean (SD)
/ Private Practice (n=15)
N (% yes) or mean (SD)
Traditional / 4+1 / Traditional / 4+1 / Traditional / 4+1
Learning Opportunities / 1-9)† / Learner Subscale / 3.54 (0.72) / 3.85 (0.77) / 3.64 (0.59) / 4.10 (0.46) / 4.28 (0.61) / 4.43 (0.62)
Faculty Teaching / 10-20)† / Faculty Subscale / 4.09 (0.75) / 4.12 (0.79) / 4.11 (0.56) / 4.33 (0.44) / 4.71 (0.47) / 4.71 (0.47)
Care
Delivery Fragmentation / 21) ‡ / Fragmentation of inpatient care / 40 (89%) / 2 (4%) / 18 (100%) / 0 (0%) / 13 (87%) / 0 (0%)
22) ‡ / Inpatient handoffs / 27 (60%) / 2 (4%) / 18 (100%) / 0 (0%) / 13 (87%) / 1 (7%)
23) ‡ / Competing inpatient & outpatient responsibilities / 40 (89%) / 2 (4%) / 10 (100%) / 14 (11%) / 14 (93%) / 0 (0%)
24) ‡ / Interruptions/delays in providing outpatient care because of inpatient responsibilities / 37 (82%) / 2 (5%) / 18 (100%) / 0 (0%) / 10 (67%) / 0 (0%)
25) ‡ / Travel time between clinic & inpatient units / 40 (89%) / 1 (2%) / 7 (41%) / 0 (0%) / 10 (67%) / 0 (0%)
26)† / Number of interruptions in typical clinic afternoon to attend to inpatient responsibilities / 5.28 (2.47)b,c / 0.11 (0.47)a / 3.05 (1.78) / 0.11 (0.32)a / 2.71 (3.34) / 0.13 (0.52)a
27) † / Clinic schedule supports continuity of care / 2.34 (0.99)b / 4.19 (0.93)a / 2.17 (1.10)b / 4.50 (0.79)a / 3.20 (1.15) / 4.27 (0.80)a
Satisfaction with Ambulatory Training / 28)‡ / I feel satisfied with ambulatory experience / 2.95 (1.20)b / 3.67 (1.04)a,b,c / 2.83 (0.99)b / 4.50a (0.51) / 3.80 (1.08) / 4.87 (0.35)a
29) † / Outpatient internal medicine is enjoyable / 3.18 (1.13) / 3.32 (1.38)b,c / 2.83 (0.92)b / 4.06 (1.00)a / 3.80 (1.01) / 4.80 (0.41)a
30) ‡ / Your own personal stress of having to attend clinic while on a hospital rotation / 43 (96%) / 1 (2%) / 18 (100%) / 0 (0%) / 14 (93%) / 0 (0%)
31)† / I feel ownership for my patients in ambulatory clinic / 2.82 (1.04)c / 3.88 (0.88)a,c / 2.17 (1.04)b / 4.56 (0.51)a,b / 3.27 (1.10) / 3.73 (1.03)
32)† / I am able to focus on my outpatient education while in clinic / 2.66 (1.18) / 3.91 (1.15)a,b,c / 2.39 (4) / 4.78 (0.43)a / 3.07 (1.58) / 5 (0)a
33)† / My continuity experience makes me confident that I could safely and competently practice general internal medicine after residency / 3.11 (0.90)c / 4.28 (0.75)a / 3.61 (1.15) / 4.16 (0.78)a / 3.73 (1.03) / 4.40 (0.63)a
†Please rate how strongly you agree with each of the following statements: 1= strongly disagree; 5= strongly agree
‡When thinking about your inpatient and outpatient responsibilities this year and last year, please rate how problematic the following are/have been for you: yes; no
a Indicates significant difference (p0.05) between training models within the setting
bIndicates significant difference (p0.05) from PP within the model
cIndicates significant difference (p0.05) from HBC within the model
Table 3: Nominal Group Data of Residents, Faculty, Staff evaluating 4+1 Model of Training †
Resident (n=20) / Faculty (n=18) / Staff (n=8)Strengths
Learning Opportunity / Structured ambulatory teaching / 13 / Ability to focus on the clinic and not be distracted by floor and care there / 2
Faculty
Teaching / work with multiple attending during clinic time / 2 / Education and teaching time is more positive; more positive interaction and contact time with faculty-residents / 12
Better exposure/experience/systems of care over the week with patients / 8
Care Delivery Fragmentation (CDF) / Inpatient medicine no longer fragmented / 23 / Inpatient continuity, Outpatient continuity / 11 / Continuity of patient care / 2
Continuity with outpatients is evident / 17 / Patient care and safety… in Inpatient setting / 19 / Adequate residents in clinic who come as scheduled / 1
Availability of residents – Distribution among outpatient and inpatient time / 5 / Logistics of making resident scheduling is improved / 6
Satisfaction / Light rotation taken every 5 weeks / 11 / Resident satisfaction / 17 / Resident quality life / 2
Less travel time on weekly basis / 4 / Continuity of site for a week makes resident evaluation easier for attendings who interact with trainee / 2
Less personal stress-schedule / 20 / For administrative requirements, easier to gather residents during clinic week to assure other things get done. Group of residents in one place at one time; Easy to locate residents / 2
Weaknesses
Difficulty for Follow-up of Sick Patients / Sick patients get less continuity of care / 9 / Outpatient continuity needs to be sooner than 5 weeks especially for lab results, images, chronic pain management / 12 / More frequent patient follow up needed at 1, 2, 3, and 4 week; if cannot see their physician, patients need to schedule with someone else / 4
Follow up on teaching points is harder with 5 week intervals / 2 / Feedback to residents is difficult if reports come back later in week...Lose continuity on resident education for patients seen later in the week. / 1
Evaluation system is more difficult due to end date being staggered; Evaluation is more delayed and.more complex. / 4
Every week is a switch for faculty and residents. Cannot keep track of their activities…lose pulse of the residents in the program. / 2
† Numbers in table represent the number of times each strength/weakness was mentioned by participants
Figure 1: Schematic of 4+1 Model of Training
Week of theAcademic
year / FIRM 1 / FIRM 2 / FIRM 3 / FIRM 4 / FIRM 5
Week 1 / AMB Ambulatory week
Week 2 / AMB Ambulatory week
Week 3 / AMB Ambulatory week
Week 4 / AMB Ambulatory week
Week 5 / AMA Ambulatory week
Week 6 / AM A Ambulatory week
Week 7 / AMB Ambulatory week
Week 8 / AMB Ambulatory week
… / AMB Ambulatory week
Week 52 / AMB Ambulatory week
Figure 2: Self-Reported Empanelment
(PCMH= Patient Center Medical Home, PP=Private Practice)
Clinic site training model type interaction:
F(2,142)=4.43, p=0.014
HBC<PCMH, p=0.0003; HBC>PP, p=0.0002