Achieving the AAAs of Ambulatory Care: Aptitude, Appeal, and Appreciation Open Access

As lengths of hospitalizations have decreased, more patient care is done in ambulatory primary care settings; however, fewer residents are pursuing primary care careers.1 Barriers to residents developing a sense of competence and enjoyment in ambulatory medicine include the complexity of practice-based systems, patients with multiple chronic diseases, paucity of role models, and the limited time that residents spend in primary care clinics.

As new Accreditation Council for Graduate Medical Education (ACGME) guidelines support enhancing longitudinal care, efforts must be made to enhance the aptitude, appeal, and appreciation of residents' experiences in the continuity clinic. To avoid unintended consequences such as increased dissatisfaction with continuity clinic, it is important to implement quality improvements and to avoid simply increasing exposure to negative experiences.2 

Each ambulatory clinic site represents an individual system of care. Until new interns learn how to care for patients in their “continuity care system,” they will be relatively ineffective and inefficient as they attempt to provide ambulatory care. Additional barriers may exist for international medical graduates. These graduates must adjust to a change in status, as well as new expectations of language proficiency, interpersonal skills, and new educational and clinical systems.3 

To overcome barriers of competency and satisfaction in ambulatory practice, we sought to enhance the learning environment by equipping interns with the skills they need to practice in this setting early in their residency. We developed a structured, competency-based, multidisciplinary curriculum for initiation into the ambulatory practice. We describe our experience with 2 subsequent classes of interns who had a 1-week, full-time immersion in the ambulatory setting prior to beginning their longitudinal continuity clinic, with no competing clinical responsibilities. Individual instruction was provided throughout the week by a single faculty champion, allowing for consistency in observation.

The study took place in the University of Tennessee College of Medicine-Chattanooga general internal medicine primary care continuity clinic at the Baroness Erlanger Hospital and was qualified for waiver by the institutional review board.

General internal medicine interns beginning their first year of training participated in the mandatory clinic orientation during July or August of their intern year in 2007 and 2008.

In 2006, prior to the study, baseline data regarding barriers to care was solicited qualitatively by asking residents (postgraduate year [PGY]1-3) open-ended questions about what went well in clinic and what did not go well on a particular clinic day. The responses were anonymous and grouped into 3 categories: staff barriers, patient barriers, and resident barriers to efficiency (figure 1). Ninety percent of residents responded to the baseline survey. The preorientation data regarding barriers to care were used in part to develop the curriculum. Items from the survey that warranted intervention included the following: (1) check-in and discharge process was too slow, (2) nurse did not seem pleasant or approachable, (3) attending checkout time too long, (4) paperwork was duplicative, (5) charts needed to be more organized, and (6) patients were complex. Prior to orientation, the “firm” system was developed as the results of baseline data underscored the need for team-building to improve resident and staff relations. Each firm consists of a small group of residents, faculty, and clinic staff who function as a group practice within the larger practice. Residents also noted that attending checkout was a barrier. The curriculum focus on presentation skills was thought to be paramount to improve delayed checkouts. The barriers noted in the organization and efficiency of the clinic highlighted the need for the interns to understand the clinic systems.

An attending physician (A.H.R) from the core faculty who routinely supervises in the residents' clinic was designated as faculty champion. During a regularly scheduled staff meeting, the faculty champion discussed goals and objectives of the orientation week and obtained input from team members. The core faculty provided continuous feedback about the needs of the interns and the development of the curriculum. They also reviewed teaching and learning tools and the schedule of events.

As collaboration with other disciplines is thought to be a necessary first step toward developing physicians who can provide comprehensive care and enhance health care outcomes, a multidisciplinary team was used.4 Team members included the clinic manager, clinic nursing staff, medical technologist, health information technologist, laboratory personnel, patient representative, clinical diabetes educator, clinical pharmacist, and clinic faculty. Each team member was asked his or her views on what were the most relevant items in his or her area that should be included in the orientation. They met as a group and then subsequently individually with the faculty champion to define their contribution to the orientation. To further improve the functioning as an interdisciplinary team, “Breakfast with the Stars,” a breakfast with the clinic staff, was introduced into the curriculum to occur each week with the orienting intern(s) and attending faculty. Sharing a meal, hearing the interns' personal stories, and all participants sharing responses to an icebreaker question was used to facilitate bonding among the new interns, faculty, and clinic staff.

The curriculum was developed to highlight all 6 of the ACGME core competencies (www.acgme.org) and address the barriers identified from the baseline survey. The curriculum focused on systems-based practice, patient safety, quality improvement, collaboration and teamwork, emphasizing the importance of continuity of care, and long-term doctor-patient relationship. The medical knowledge competency was assessed by asking interns to complete an assigned portion of standards of medical care in diabetes,5 apply knowledge of diabetes care in clinical scenarios, and direct patient care. The interns developed preventive services care plans for assigned patients (www.ahrq.gov and www.immunize.org ) and the American College of Physicians pain curriculum was added to the curriculum in 2008 (www.acp.org). To assess the patient care competency, direct observation of patient care was emphasized. Interns demonstrated their ability to write prescriptions independently. Simulator models were used to enhance physical examination skills after reviewing the New England Journal of Medicine video for the pelvic examination.6 In addition, interns demonstrated and documented appropriate history-taking and physical examination skills, culminating in the mini-clinical evaluation exercise (mini-CEX) on the last day of the orientation.

The practice-based learning and improvement competency was assessed by asking interns to use resources for information needed for patient care and patient scenarios, conduct at least 2 chart audits, and develop a diabetic care plan based on standards of care using chart audits. Interns also reviewed a sample of the clinic's narcotic agreement. The interpersonal and communication skills competency was assessed by: (1) showing residents the correct use of the “exam room flags,” a system to notify nursing staff in which examination room the resident is located and when a patient is ready for nursing discharge; (2) observing interns communicating diagnoses, treatment plans, and follow-up care correctly to patients; (3) meeting with clinic registration staff, medical records staff, and nurses to understand their roles; and (4) presenting patients to the attending physician using the format in “Patient Care and Communication.”7 Current problem lists were created and maintained. Interns demonstrated proper completion of referral and laboratory forms. Interns participated in the team-building breakfast, “Breakfast with the Stars.”

The professionalism competency was evaluated and emphasized by noting residents' arrival to clinic sessions on time, professional attire, and presentation (eg, no scrub attire, body odor, halitosis). Interaction with the office staff as a member of the team and willingness to learn from team members was emphasized. Interns were evaluated on their ability to include patient preferences when selecting diagnostic and therapeutic options. As all encounters were directly observed, honesty and accuracy in documentation and delivery of culturally competent care could be readily assessed. Approximately 60% of our interns during the study period were international medical graduates, so the need to assess and teach the systems-based learning competency was paramount. Interns were taught the purpose of the firms and the responsibilities of each member. We ensured that interns could write orders legibly and accurately. Interns observed the “Coumadin clinic” in action, reviewed patient assistance programs and formularies, and reviewed resources for finding International Classification of Diseases, ninth revision, codes and incorporating them when needed for diagnostic services.8 

The designated curriculum items were arranged into a weekly schedule along with scheduled time with a representative of each staff position (table 1).

The faculty champion was given protected time to participate in the process and orient all interns. Interns were excused from all other clinical duties for 1 week to participate in the clinic orientation. Interns did not begin their individual continuity experience until completing the orientation week. Faculty from other rotations were contacted to obtain and provide clinical support in the absence of the intern from their assigned monthly rotation. During the first year of the orientation, interns worked one-on-one with the faculty champion. In year 2, to improve efficiency and combine resources, 2 interns were paired with this faculty champion each week. We maintained a single faculty champion to provide consistency in rating the mini-CEX. With the exception of direct patient encounters, all activities were conducted simultaneously for both interns during the second year of the study.

Feedback on clinical performance, including patient communication, history-taking, physical examination, documentation, and interaction with staff was offered throughout the orientation. To evaluate aptitude, appeal, and appreciation at the end of each week of immersion orientation, interns were required to complete a written open-book test. The posttest consisted of 24 multiple-choice questions and 3 patient scenarios that required the intern to develop a care plan using current clinic procedures such as laboratory forms, order forms, referrals, and patient assistant program for obtaining medications for indigent patients. Specific areas tested are noted in table 2. The results of the open-book posttest were personally discussed and reviewed with the intern by the faculty champion. In addition, the intern completed a competency-based rotation goals and objectives checklist during a face-to-face session to ensure completion of the curriculum and provide written feedback by the single faculty champion. The written evaluation for each of the competency areas was provided to the intern and the program director, and was discussed with core faculty.

Interns evaluated the rotation at the end of the week. The interns' evaluation of the immersion experience done at the end of the week had 3 open-ended questions, giving the opportunity for the intern to indicate at least 3 things that were beneficial in the immersion experience, 3 things that needed improvement, and an “other” category for comments.

In order to compare interns who underwent the week-long orientation with their upper-level peers who had not undergone the immersion orientation, a web-based survey composed of 32 statements pertaining to processes of care was given to residents of all PGY levels 3 months after the orientations were completed (table 3). Comparison of self-assessed proficiency in the ambulatory clinic between the interns who had the immersion orientation experience with residents at PGY-2 and PGY-3 was done using a 5-point Likert scale (1  =  disagree strongly, 3  =  neutral, 5  =  agree strongly). The survey was repeated for the new interns in 2008.

In the first year of the study, when compared with upper-level residents, interns undergoing orientation were more certain of their knowledge of staff roles, systems issues, and familiarity with chart forms and documentation requirements than residents at PGY-2 and even the PGY-3 levels (figure 2). When we compared results of orientation in 2007 with those in 2008, we found an increase in the perceived knowledge areas by the interns who participated in the 2-to-1 faculty orientation (figure 3). The interns who completed the orientation curriculum were able to conduct an ambulatory visit with a level of independence usually not attained until much later in residency, based on direct observation by faculty preceptors and clinic staff. All participants in the experience agreed or strongly agreed that the orientation was helpful in understanding the clinic system. When asked to make general comments, 100% of interns noted appreciation for their faculty champion and thought that the session met their goals as designed in 2007 and 2008.

The immersion orientation experience equips the intern early in his or her training with multiple competencies. Interns participating in the orientation rated the experience highly. Their patient care evaluated by a single faculty member utilizing the Mini-Clinical Evaluation Exercise (CEX) may allow for less variability in the assessment of ambulatory clinical skills.9 Baseline medical knowledge of some of the most common ambulatory topics (preventive medicine, diabetes guidelines, and pain management) can be taught and assessed. Chart audit as a method of practice-based learning and improvement begins early in training and hopefully will continue, as past studies have shown that chart audits may serve as practical and cost-effective way to stimulate self-reflection in residents' continuity practice.10,11 Assessing these competencies early in training directs our residency program's attention in the continuity clinic to key areas important to internal medicine training.12 

Willet and colleagues13 recently showed that standard measures for resident assessments such as attending global evaluations, in-training examination, and mini-clinical examination exercise weakly correlated with measuring clinical outcomes assessed by chart audits, supporting the ACGME recommendations to incorporate multiple assessment tools. In addition to chart audits, we used checklist evaluations of the competencies, written examinations, and simulations and models.

Interpersonal skills and communication were assessed directly by the attending physician and the interdisciplinary team. Professionalism demonstrated by honesty and accuracy in documentation is established by the focused attention to each encounter by the faculty champion. The interns experienced the necessity and accountability of completing assignments. Practice in the ambulatory setting requires system-based learning of the unique practice setting. Skills attained in understanding the care system can encourage the resident to seek to enhance quality and safety in patient care.

We demonstrated that interns who had extensive orientation perceived more satisfaction and comfort with working in our outpatient clinics. Furthermore, orienting more than 1 intern per week showed even better perception of the ability to understand the clinic staff roles and systems. Not only did working 2-on-1 improve efficiency of the process, but potentially it may have allowed support and camaraderie between interns. Although we were unable to randomize, our study showed that third-year residents who did not participate in the orientation did not feel as comfortable with many of the clinic processes despite more experience. Although the current study shows that interns in our study indicate that the immersion in an intensive, hands-on experience using a structured ambulatory care orientation curriculum early in training enhances familiarity with many of the clinic systems, longitudinal randomized trials would have to be done to determine long-term outcomes and the impact on future practice patterns and satisfaction with ambulatory care. Future studies to assess interns' competence in the various aspects of the clinic during the second or third year using the posttest questions and mini-CEX may be useful to help modify and improve the orientation process.

Our study has some limitations. It is a pilot project and was not designed to confirm whether working 1-on-1 with a faculty champion, being more aware of clinic process, or participating in various teaching and learning activities led to the interns' highly favorable view of the experience. Recruiting a single faculty champion gives a unilateral perspective. Nevertheless, our faculty champion remains a future resource and role model. Satisfaction with preceptors, particularly as role models, and clinic operations correlate with the value residents place on continuity clinic.14 

The immersion of interns in an intensive, hands-on experience using a structured curriculum can improve aptitude–interns' ambulatory clinic skills and the opportunity to evaluate them early in their training, assess baseline knowledge, and set learning goals; appeal–spending time with staff and colleagues potentially improves overall morale and clarifies expectations; and appreciation–of the ambulatory care setting as one in which high-quality, effective care can be provided with the support of an interdisciplinary team. Preparing internal medicine residents to have a rewarding experience in continuity clinic represents a long-term challenge.