Jun 15, 1993 - through fee-for-service billing. The respondents felt that the ideal program should contain a mix of general and subspecialty ambulatory care ...
ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE
Ambulatory care training during core internal medicine residency training: the Canadian experience Peter J. McLeod, MD, FRCPC; Timothy W. Meagher, MB, FRCPC Objective: To determine the status of ambulatory care training of core internal medicine residents in Canada. Design: Mail survey. Participants: All 16 program directors of internal medicine residency training programs in Canada. Outcome measures: The nature and amount of ambulatory care training experienced by residents, information about the faculty tutors, and the sources and types of patients seen by the residents. As well, the program directors were asked for their opinions on the ideal ambulatory care program and the kinds of teaching skills required of tutors. Results: All of the directors responded. Fifteen stated that the ambulatory care program is mandatory, and the other stated that it is an elective. Block rotations are more common than continuity-of-care assignments. In 12 of the programs 10% or less of the overall training time is spent in ambulatory care. In 11 the faculty tutors comprise a mixture of generalists and subspecialists. The tutors simultaneously care for patients and teach residents in the ambulatory care setting in 14 of the schools. Most are paid through fee-for-service billing. The respondents felt that the ideal program should contain a mix of general and subspecialty ambulatory care training. There was no consensus on whether it should be a block or continuity-of-care experience, but the directors felt that consultation and communication skills should be emphasized regardless of which type of experience prevails. Conclusions: Although there is a widespread commitment to provide core internal medicine residents with experience in ambulatory care, there is little uniformity in how this is achieved in Canadian training programs.
Objectif: Determiner l'etat de la formation en soins ambulatoires des residents du programme de tronc commun en medecine interne au Canada. Conception: Sondage postal. Participants: Les 16 directeurs des programmes de formation des residents en medecine interne au Canada. Mesures des resultats: La nature et la duree de la formation en soins ambulatoires donnee aux residents, des renseignements sur les directeurs d'etudes, et les sources et les types de patients traites par les residents. De plus, on a demande aux directeurs de programmes leurs points de vue sur le programme de soins ambulatoires ideal et le genre d'aptitudes A 1'enseignement exigees des directeurs d'etudes. From the Department of Medicine, Montreal General Hospital, and McGill University, Montreal, Que.
Reprint requests to: Dr. Peter J. McLeod, Department of Medicine, Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G ]A4 JUNE 15, 1993
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Resultats: Tous les directeurs ont repondu. Quinze ont mentionne que le programme de soins ambulatoires est obligatoire, et l'autre a declare qu'il est facultatif. Les roulements par blocs sont plus frequents que les affectations de suivi des soins. Dans 12 programmes, on consacre 10 % et moins du temps global de formation aux soins ambulatoires. Dans 11 programmes, les directeurs d'etudes se repartissent entre l'omnipratique et des sous-specialites. Dans 14 programmes, les directeurs d'etudes traitent des patients en meme temps qu'ils enseignent aux residents dans le contexte des soins ambulatoires. La plupart d'entre eux sont remuneres a l'acte. Les repondants ont estime que le programme ideal devrait comporter une formation mixte en soins ambulatoires d'omnipratique et de sous-specialites. Les opinions divergent sur ce que devrait etre l'experience par blocs ou par suivi des soins, mais les directeurs estiment qu'on doit mettre l'accent sur les aptitudes a la consultation et a la communication quel que soit le type d'experience choisi. Conclusions: Bien que l'on s'engage generalement a donner une experience des soins ambulatoires aux residents du programme de tronc commun en medecine interne, les programmes de formation canadiens emploient divers moyens pour y parvenir.
T he recent resurgence of interest in teaching clinical medicine in ambulatory settings has come about largely because of changes in the makeup of patient populations in teaching hospitals. 1-4 Economic and social forces have had a major impact on the spectrum of diseases and the types of patients on medical wards: residents now deal largely with seriously ill patients, often with multisystem or terminal illnesses, who require hightechnology tertiary care. As a result the inpatient arena is losing its educational utility,5 and ambulatory settings must now provide exposure to the types of patients admitted to hospitals as recently as 15 years ago. Clinicians of tomorrow will need the skills and judgement currently best learned in ambulatory settings through the treatment of chronic illnesses such as hypertension and arthritis, longitudinal re-
da. We conducted a follow-up mailing to nonresponders 6 weeks after the initial mailing and contacted by phone those who still failed to respond. The first section of the questionnaire requested general information about the residents, including the year ambulatory care training is offered, whether the training is provided as a block rotation or as continuity-of-care assignments, how much time residents spend in ambulatory care training, the type of patients seen and the residents' attitudes toward the training. The second section sought information about the faculty members: the number of trainees under their tutelage, which teaching vehicles they prefer, their university appointments and their attitudes toward the ambulatory care training. Section three related to the sources and types of patients. The fourth section solicited opinions from the prosponsibility for patient well-being, decision making gram directors on the "ideal" ambulatory care exabout when to admit patients and the treatment of perience and what kinds of teachers with what teaching skills should be responsible for it. acute illnesses not requiring hospital admission. All of the questions were open-ended, and reThe Royal College of Physicians and Surgeons of Canada, recognizing that a limited portion of the spondents were invited to write comments at the end average physician's practice involves the care of of each section of the questionnaire. patients in hospital, recently published a discussion paper on ambulatory care in specialty residency Results training.6 It underscored the increasing importance of ambulatory care experience in the training of We received analysable responses from all of the competent physicians. program directors. To facilitate the development of our plans for clinical education of residents in the ambulatory Nature and amount of training experienced setting we conducted a survey to determine the by residents status of ambulatory care training of core internal medicine residents in other Canadian medical Fifteen of the directors reported that ambulaschools. tory care training is mandatory for core internal medicine residents; the other stated that it is offered as an elective. The years during which the training is Methods offered is shown in Table 1. In four of the schools We developed a four-part questionnaire on am- the year varies depending on the specific hospital bulatory care experiences of core internal medicine in the program and the level of training of the residents and mailed it to each of the 16 directors of resident. Most of the schools offer the experience as internal medicine residency programs across Cana- a block rotation (Table 1). Residents in almost all of 2144
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the programs reportedly provide a mixture of secondary and tertiary care, but in one program they do consultations only. All of the directors indicated that the average ambulatory care session is 3 to 4 hours long; in 12 of the schools the ambulatory care training accounts for 10% or less of the overall training time in internal medicine. Of the 11 directors who stated that the service:education ratio is different in the ambulatory clinic than on the hospital wards 8 indicated that there is less service requirement in the ambulatory setting; the other 3 indicated that the ratio depends on the particular ambulatory care supervisor. When
Variable Year training given 2 and 3 1,2 and 3 3 only
Variable'
Type of training Block rotation
Continuity-of-care assignments Combination Proportion of total training time in ambulatory care, %fO < 10 1 1-20 > 20 Variable*
No. of programs 5 4 3 4 10 5 1
12 2 1 1
Sources and types ofpatients
1
General internists only
5
Teach and see patients
14 1 I
Teach only Variable* No. of tutors per resident >-1 1 Variable* Teaching vehicles used Patients seen Patients seen. as well as seminars and mninHiectures1 3 'Vars with Individual tutort JUNE 15, 1993
Characteristics offaculty members The characteristics of the faculty tutors are presented in Table 2. In most of the programs the tutors are a mixture of general internists and subspecialists. Most tutors are paid through fee-for-service billing. Nine of the directors reported that the tutors generally enjoy their role in ambulatory care teaching; the others stated that the tutors are less positive and have described the training as "demanding of time," "labour intensive," "hectic and unsatisfying" and "compromising of income."
'Varies depending on the specific hospial In the program and the level of training of the resident.
subspecialists
asked if the residents' inpatient duties interfere with their ambulatory care responsibilities, eight program directors said Yes and eight said No. Residents' attitudes toward the ambulatory care experience have been positive according to 13 of the respondents, indifferent or ambivalent according to 2 and variable depending on the resident's level of training according to 1. In response to the question about subspecialty ambulatory care experience, the program directors indicated that all trainees undergo such training, usually during subspecialty rotations and during the senior years of training. Although residents in general reportedly have spent more ambulatory care time in subspecialty programs than in core internal medicine programs there is no uniformity in the patterns, timing or type of ambulatory care across the subspecialty programs.
12 3 1
13
Ten of the directors stated that the training occurs in hospital ambulatory care clinics; the others reported that it is provided in both hospital clinics and private physicians' offices. Only two programs have used rural clinics, and none has used community clinics or home-care settings. In all programs the socioeconomic characteristics of the patients are similar to those of patients seen in private offices. Patients are referred from emergency departments, hospital wards after discharge or other subspecialty clinics or by physicians. In most of the programs the patients come from a combination of these sources. All of the program directors felt that the case mix in the ambulatory settings is adequate or favourable.
Opinions on the ideal ambulatory care program According to the 13 program directors who answered the question about the desirable balance between general medicine and subspecialties, residents should have a mix of general internal medicine and subspecialty training in ambulatory care. Eight of the 13 felt that more time should be spent in CAN MED ASSOC J 1993; 148 (12)
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subspecialty than in general internal medicine training. Seven favoured continuity-of-care experience for general medicine, six a block rotation and three a mixture. All but one of the directors stated that the best forms of evaluation in ambulatory settings are direct observation and case discussion; the other recommended videotaping the interactions between trainees and patients. Seven felt that the teaching skills of tutors in the outpatient setting differ from those of tutors in the hospital setting; five stated that they do not differ. Among the teaching skills noted to be especially useful in ambulatory settings are ability to teach residents about communication skills, practice management and interpersonal skills and ability to transmit knowledge of economics, bioethics and behaviour. When the program directors were asked to rate the importance of 19 components of an ambulatory care program on a five-point scale, consultation skills and communication skills had, on average, the highest ratings, whereas orthopedics and gynecology had the lowest rating (Table 3). The directors commented liberally about areas not specifically addressed in the questionnaire. Many indicated that there have been logistic difficulties in assigning residents to clinics or offices for experience in longitudinal care. Others indicated that inadequate physical resources have hampered efforts to expand the ambulatory care training program. Two indicated plans to move from block rotations to continuity-of-care clinics.
Skill/topic Consultation skills
mean score, (ana
standard deviation) 4.87 (0.35) 4.67 (0.49) 3.79 (0.89) 3.67 (0.90) 3.57 (1.34) 3.43 (1.02) 3.43 (1.02) 3.40 (0.99)
Communiction skills Critical literature analysis Longitudinal experience Decision aralysis Quality assurance Preventive medicine Bicethics
Uroloy
3.27(0.59) 3.20 (1.32) 3.15 (1.07) 3.13 (0.99) 3.0)7 (1.14) 2.33 (0.72) 2.33 (0.72)
Otbrhlnolaynoog5y
2;20(0.56)
Dermatology
M ioal eco.o lnomics Te.adhnilds Office administration Behavioural medicine Nutrition
2.13 (0.52)
1.95 0.85)
Or hop
The dects were ad to ra_ the co on on a fivp scab: 1-Very umt22 uniPortmnut 3 of some ImpOr 4 - important and 5- very Importnt. -
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,
Discussion Our findings indicate a widespread commitment to training core internal medicine residents in ambulatory care settings. The most prevalent model is a
block rotation, in which residents spend a finite period (usually 1 or 2 months) in intense ambulatory care training. In some of the programs there are concurrent inpatient assignments, whereas in others the block rotation is totally committed to ambulatory patients. Continuity of care is the hallmark of ambulatory care, but this type of training is offered in fewer than half of the programs. Both systems have advantages and disadvantages, and the debate continues as to which provides the best educational experience, although there is evidence that patients prefer the continuity-of-care model.7 Perhaps a mixture of block and continuity-of-care experiences would be optimal. In most of the programs residents spend less than 10% of their overall training in ambulatory care settings. A study from the United States indicated that first-year residents in internal medicine spend 18% of their time in such settings.8 Concerns among internists that past residency experiences did not provide adequate exposure to ambulatory patients influenced the American Accreditation Council for Graduate Medical Education to state that "at least 25% of the 3 years of residency training must be in the ambulatory care setting."9 Others might argue that time in ambulatory settings at the expense of exposure to seriously ill patients in hospital might "threaten to reduce clinical skills and deep competence and thereby reduce rather than enhance effectiveness in the care of ambulatory patients."10 Our findings indicate that ambulatory care experience continues to run a poor second to inpatient teaching as a learning experience in the minds of some program directors, some faculty tutors and some junior residents. Dissatisfaction among program directors and faculty tutors with the state of ambulatory care learning can have a powerful negative effect on residents' attitudes. It is not surprising if residents, especially those in the first 2 years, are not enthusiastic about their ambulatory care experience. Junior trainees experience the "romance" of medicine on the wards, where critical illness and dramatic technology predominate. It is not until the senior years that residents perceive the relevance and educational value of ambulatory care. 'i A number of approaches are possible to improve faculty members' attitudes toward ambulatory care teaching. Medical schools could institute features such as merit recognition and protected time for teachers. Specific funding might lessen the economic demands of the setting and allow tutors to concentrate on teaching. Tutors who, during clinics, can LE 15 JUIN 1993
devote more time to teaching and less time to patient care away from trainees will find the work more rewarding and will contribute more to resident learning. We did not solicit information about the knowledge, skills and attitudes currently emphasized in Canadian ambulatory care programs. There is no reason to expect that the emphasis and deficiencies are any different from those reported from two studies of graduates of residency programs in the United States.'2"3 Although some of these were identified by graduates of a primary care program, they still may have relevance in the Canadian context. Among the gaps in their ambulatory care training the graduates cited orthopedics, dermatology, office management, occupational medicine, physical therapy and nutrition. Perhaps the Canadian Association of Internal Medicine Program Directors should develop new objectives for ambulatory care training based on the directors' opinions of the ideal program and the graduates' perceptions of training deficiencies. Whatever the solution, it is timely to consider collectively what the optimum approach is to ambulatory care training for internal medicine residents.
References 1. Peckoff GT: Teaching medicine in the ambulatory setting. An idea whose time has finally come. N Engl J Med 1986; 314:
27-31 2. Davidson RA: Changes in the educational value of inpatients at a major teaching hospital: implications for medical education. Acad Med 1989; 64: 259-261 3. Barker LR: Curriculum for ambulatory care training in medical residency. J Gen Intern Med 1990; 5 (suppl): S3-S 14 4. McSherry J: Let's put the teaching of clinical skills where it belongs. Can Med Assoc J 1990; 142: 386-387 5. -Griganti MA, Fletcher GW: Residency training in the inpatient setting: a new dilemma for internal medicine. J Gen Intern Med 1989; 4: 136-138 6. Accreditation Committee: Discussion paper on ambulatory care in specialty education. R Coll Physicians Surg Can Office Training Eval Newsl 1992; 2: 1-2 7. Brook RH, Fink A, Kosecoff J et al: Educating physicians and treating patients in the ambulatory setting. Ann Intern Med 1987; 107: 392-398 8. Anderson RM, Lyttle C, Kohrman C et al: National Study of Internal Medicine Manpower: XVII. Changes in the characteristics of internal medicine residents and their programs. Ann Intern Med 1990; 113: 243-249 9. Whartman S: The residency review committee and the "25 percent rule." Soc Res Educ Primary Care Intern Med Newsl 1985; 7: 2-3 10. Barondess J: The training of the internist. Ann Intern Med 1979; 90: 412-417 11. Schroeder S, McPhee J: Training internists in ambulatory settings [EJ. Arch Intern Med 1986; 146: 1685-1686 12. McPhee S, Mitchell T, Schroeder S et al: Training in a primary care internal medicine residency program. JAMA 1987; 258: 1491-1495 13. Linn L, Brook R, Clark V et al: Evaluation of ambulatory care training by graduates of internal medicine residencies. JMedEduc 1986; 61: 293-302 JUNE 15, 1993
Conferences continued from page 2139 Sept. 4-10, 1993: 1 5th World Congress of Neurology (sponsored by the World Federation of Neurology and the Canadian Neurological Society) Vancouver Secretariat, 645-375 Water St., Vancouver, BC V6B 5C6; tel (604) 681-5226, fax (604) 681-2503
Sept. 5-9, 1993: European Atherosclerosis Society 62nd Congress Jerusalem, Israel Gil-Kenes, 946-1617 J.F.K. Blvd., Philadelphia, PA 19103, tel (800) 223-3855, fax (215) 568-0696; or Secretariat, 62nd European Atherosclerosis Society Congress, PO Box 50006, Tel Aviv 61500, Israel, tel 011-972-3-517-4571, fax 011-972-3-660-325 Sept. 5-10, 1993: Challenges in a Changing World Psychogeriatrics at the Turn of the 21 st Century: 6th Congress of the International Psychogeriatric Association (IPA) Berlin, Germany Abstract deadline: Apr. 30, 1993
Official language: English 6th Congress of the IPA, GEROCON Geriatric Medicine, Consulting GmbH, Im Hoppenkamp 4, 5060 BergischGladbach 1, Germany; tel 011-49-2204-5-20-14, fax 01 1-49-2204-5-20-15
Sept. 7-10, 1993: 6th International Congress on Interventional Ultrasound Copenhagen, Denmark Christian Nolsoe, Congress Secretary, Department of Ultrasound, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark
Sept. 9-11, 1993: 2nd International Congress on Peer Review in Biomedical Publication (sponsored by the American Medical Association) 'Chicago Annette Flanagin, North American coordinator, Peer Review Congress, JAMA, 515 N State St., Chicago, IL 60610, tel (312) 464-2432, fax (312) 464-5824; or Jane Smith, European coordinator, Peer Review Congress, BMJ, BMA House, Tavistock Square, London WC1H 9JR, England, tel 011-44-1-71-387-4499, fax 011-44-1-71-383-6418 Du 9 au 13 sept. 1993: Les soins specialises en crise? -
62e Assemblee annuelle du College royal des medecins et chirurgiens du Canada Vancouver Anna Lee Chabot, chef, section des reunions et assemblees, Bureau des affaires des Associes, College royal des medecins et chirurgiens du Canada, 774, prom. Echo, Ottawa, ON KIS 5N8; tel (613) 730-6233 ou (613) 730-8177; fax (613)730-8830
continued on page 2154 CAN MED ASSOC J 1993; 148 (12)
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