As internal medicine (IM) residents decide to pursue general IM versus fellowships, they may gravitate toward experiences with which they are more familiar and comfortable. We commend Dulay and colleagues1 on implementing a 3-week intensive continuity clinic experience that was shown to improve intern satisfaction and confidence with outpatient skills. Across the nation, more IM residency programs have implemented an X + Y schedule with dedicated inpatient or outpatient weeks, replacing the weekly clinic during the inpatient month.
Our analysis of Dulay and colleagues' findings prompts us to ask the following question: What are the core reasons why an extended immersive experience in continuity clinic fosters more confidence and satisfaction? We discuss 3 reasons we identified:
Compartmentalization
When residents spend the morning on the wards before rushing to afternoon clinic, priority tends to lie with the first task—the demands of the inpatient unit. An immersive experience instead would prioritize the outpatient clinic experience and scholarly reading related to ambulatory care. Having designated ambulatory time allows residents to more effectively engage in the rapidly changing interface of outpatient medicine and pursue meaningful quality improvement projects as potential drivers of change. This protected time for practical and theoretical clinic education gives residents the tools to thrive in the outpatient world, makes its breadth seem more accessible, and privileges its significance.
Continuity of Acute Problems
Much of the work associated with seeing outpatients occurs after the patient has left the appointment. A dedicated, immersive experience in the outpatient setting likely more closely mimics the continuity concept associated with following a patient through every day of his or her inpatient course. It also allows residents to enrich their learning with immediate feedback by witnessing the downstream consequences of their diagnostic and treatment decisions through an acute illness. This type of intensive experience with daily follow-up also promotes the rapid formation of a therapeutic relationship with resident patients, and encourages a sense of ambulatory resident ownership that might otherwise take weeks or months to develop.
Creation of Longitudinal Mentorship
The richness of feedback (and recommendation letters) provided by outpatient faculty members who have known a resident for several years, through multiple immersive experiences, may exceed that of feedback given by an attending who supervises staggered weekly clinic sessions. Residents may rely heavily on emulating role models to develop their clinical technique and guide future career decisions. Additionally, immersive experiences offer the opportunity to form more cohesive relationships with clinic nurses, technicians, and administrators, which fosters an environment of teamwork that is more enjoyable for all parties and may protect against burnout.
Based on the findings of Dulay and colleagues,1 we suggest that the success of the immersion program relies on the above 3 factors. Once we understand the drivers of success, we can build on these principles to further refine the experience and potentially encourage more residents to pursue outpatient IM careers.
