Training generalist physicians

To train more generalist physicians, structural changes must be made along the continuum of medical education. Future generalists require in-depth exposure to primary care practice, with substantive experience in the longitudinal management of patient panels and the opportunity to work with successful generalist role models. Clinical training and course work must incorporate a wide range of skills and disciplines, including areas now under-emphasized, such as epidemiology, health services, and psychosocial medicine. Recommendations for structural changes to increase the generalist focus of medical education include: 1) the development within institutions of central authorities, involving departments of internal medicine, family medicine, and pediatrics, in joint efforts to foster all aspects of generalist training, including recruitment, curriculum development, community linkages, innovative approaches to training, and recognition and support for successful generalist teachers; 2) commitment of a minimum of 50% of clinical training to ambulatory care settings at both medical school and residency levels; 3) required longitudinal care experiences for all medical students and a 20% or greater time commitment to longitudinal care for internal medicine, pediatrics, and family medicine residents; and 4) increased numbers of generalist faculty and enhanced teaching skills among faculty in the outpatient environment, to guarantee increased exposure of medical students and residents to generalist role models.     

Changing habits of practice

PURPOSE: The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change. METHODS: The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance. RESULTS: Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education. CONCLUSION: This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.     

The core content of a generalist curriculum for general internal medicine,family practice,and pediatrics

The authors analyzed the educational content of the curricula developed for teaching in the generalist disciplines of pediatrics, family medicine, and general internal medicine. Fifteen educational components that constitute the core content shared by the three generalist disciplines are identified, described, and referenced. Tailoring the generalist curriculum for students and residents at the different stages of learning is reviewed, along with the refinement of the curriculum to meet the special needs of each generalist discipline. The success of a generalist curriculum will ultimately be measured by generalist career choices, quality of care, and both patient and professional satisfaction. The curricular determinants of success require institutional commitment to an educational philosophy that embraces the generalist disciplines, a core curriculum that provides education and training that are correlated with the demands of clinical practice, and generalist faculty who serve as role models, mentors, and teachers.     

Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) "best practices" for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goal--for example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing "effective medical resident teaching" courses for nonphysician faculty, and lobbying for improved systems of care.     

The medical day hospital. A new concept in ambulatory medical education

The shift of patients from inpatient to outpatient settings as a result of various well-known economic, technologic, and demographic forces presents a challenge for internal medicine residency training programs. In response, we developed a new ambulatory site for education of medical students and residents. The Ambulatory Diagnostic and Treatment Center functions as a medical day hospital serving the needs of patients requiring intensive diagnostic or therapeutic interventions on a short-term basis. The center maintains many of the educational advantages of an inpatient service including block rotations of house officers, easy access to consultants and specialized services, and daily attending rounds while providing experience in outpatient management skills. This unit represents a new concept in ambulatory education and, if adaptable to other institutions, may be a valuable component of a broad ambulatory medicine curriculum.     

The use of clinical decision-support tools to facilitate geriatric education

Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision-support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point-of-care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.     

The Impact of Role Models on Medical Students

OBJECTIVE: To explore the relationship between exposure to clinical role models during medical school and the students' choice of clinical field for residency training, and to estimate the strength of this association. DESIGN: Cross-section study. SETTING: McGill University School of Medicine, Montreal, Canada. PARTICIPANTS: Of the 146 graduating medical students in the class of 1995, 136 participated. MEASUREMENTS AND MAIN RESULTS: Clinical field chosen by students for residency training and the students' assessment of their exposure to and interaction with physician role models were the main measurements. Ninety percent of graduating students had identified a role model or models during medical school. Personality, clinical skills and competence, and teaching ability were most important in the selection of a role model, while research achievements and academic position were least important. Odds ratios between interacting with "sufficient" role models in a given clinical field and choosing that same clinical field for residency were 12.8 for pediatrics, 5.1 for family medicine, 4.7 for internal medicine, and 3.6 for surgery. Most students (63%) received career counseling and advice from their role models. CONCLUSIONS: Exposure to role models in a particular clinical field is strongly associated with medical students' choice of clinical field for residency training. Knowing which characteristics students look for in their role models should help identify the physicians who may be most influential in medical students' career choice.     

Comparing ambulatory preceptors’ and students’ perceptions of educational planning

To compare ambulatory preceptors' and students' perceptions of the use of educational planning (setting goals, assessing needs, formulating objectives, choosing methods, and providing feedback and evaluation) in the office setting, we mailed a survey, which was returned by 127 longitudinal ambulatory preceptors and 168 first-year and second-year medical students. Faculty perceptions did not match student perceptions of what occurred in the longitudinal preceptor program teaching sessions in educational planning areas. Students perceived these activities were occurring with much less frequency than faculty perceived. Medical education needs to move beyond the usual faculty development workshop paradigm to a more comprehensive educational development model that includes training both faculty and students in core educational skills. This will enable the ambulatory setting to reach its full educational potential in training future physicians.     

The Role for Clinician Educators in Implementing Healthcare Improvement

Clinician educators—who work at the intersection of patient care and resident education—are well positioned to respond to calls for better, safer patient care and resident education. Explicit lessons that address implementing health care improvement and associated residency training came out of the Academic Chronic Care Collaboratives and include the importance of: (1) redesigning the clinical practice as a core component of the residency curriculum; (2) exploiting the efficiencies of the practice team; (3) replacing “faculty development” with “everyone’s a learner;” (4) linking faculty across learning communities to build expertise; and (5) using rigorous methodology to design and evaluate interventions for practice redesign. There has been progress in addressing three thorny academic faculty issues—professional satisfaction, promotion and publication. For example, consensus criteria have been proposed for both faculty promotion as well as the institutional settings that nurture academic health care improvement careers, and the SQUIRE Publication Guidelines have been developed as a general framework for scholarly improvement publications. Extensive curricular resources exist for developing the expert faculty cadre. Curricula from representative training programs include quantitative and qualitative research methods, statistical methodologies appropriate for measuring systems change, organizational culture, management, leadership and scholarly writing for the improvement literature. Clinician educators—particularly those in general internal medicine—bear the principal responsibility for both patient care and resident training in academic departments of internal medicine. The intersection of these activities presents a unique opportunity for their playing a central role in implementing health care improvement and associated residency training. However, this role in academic settings will require an unambiguous development strategy both for faculty and their institutions.     

Impact of Duty Hour Regulations on Medical Students’ Education: Views of Key Clinical Faculty

BACKGROUND  Teaching faculty have valuable perspectives on the impact of residency duty hour regulations on medical students. OBJECTIVE  The objective of this study was to elicit faculty views on the impact of residency duty hour regulations on medical students’ educational experience on inpatient medicine rotations. DESIGN AND PARTICIPANTS  We conducted a National Survey of Key Clinical Faculty (KCF) at 40 internal medicine residency programs affiliated with U.S. medical schools using a random sample stratified by National Institutes of Health funding and program size. MEASUREMENTS  This study measures KCF opinions on the effect of duty hour regulations on students’ education. RESULTS  Of 154 KCF targeted, 111 responded (72%). Fifty-two percent of KCF reported worsening in the overall quality of students’ education compared to just 2.7% reporting improvement (p < 0.001). In multivariate analysis adjusted for gender, academic rank, specialty, and years of teaching experience, faculty who spent ≥15 hours per week teaching were more likely to report worsening in medical students’ level of responsibility on inpatient teams [odds ratio (OR) 3.1; 95% confidence interval (CI) 1.3–7.6], ability to follow patients throughout hospitalization (OR 3.2; 95% CI 1.3–7.9), ability to develop working relationships with residents (OR 2.3; 95% CI 1.0–5.2), and the overall quality of students’ education (OR 3.3; 95% CI 1.4–8.1) compared to faculty who spent less time teaching. CONCLUSION  Key clincal faculty report concerns about the impact of duty hour regulations on aspects of medical students’ education in internal medicine. Medical schools and residency programs should identify ways to ensure optimal educational experiences for students within duty hour requirements.     

The residency-practice training mismatch. A primary care education dilemma

Primary care practice requires clinical skills and knowledge that differ greatly from those required for successful completion of residency training. Discrepant clinical settings and physician responsibilities have thus created a mismatch between the educational content of residency training and the content of clinical practice, which may result in suboptimal preparation of internists, family practitioners, and pediatricians for patient care. Of equal concern, the psychosocial environment of residency does not prepare physicians for their future community and personal adult roles. Barriers to correcting this worsening mismatch include the following: (1) economic pressures to use house staff to meet service needs of hospitals, (2) changes in patient demographics and the focus of hospital-based medicine that are making hospitals progressively more unsuitable as the principal training site for primary care physicians, (3) the deemphasis of practicing physicians as role models and teachers in postgraduate training, and (4) the often heated disagreement among medical educators regarding the purpose and content of residency training. Efforts to resolve this mismatch should include the following: reexamining the educational objectives of the current system of postgraduate training, better counseling of physicians in training regarding career goals, and emphasizing the primary care physician as role models and faculty.     

Professionalism beyond medical school: An educational continuum?

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.     

Basic Biomedical Sciences and the Future of Medical Education: Implications for Internal Medicine

The academic model of medical education in the United States is facing substantial challenges. Apprenticeship experiences with clinical faculty are increasingly important in most medical schools and residency programs. This trend threatens to separate clinical education from the scientific foundations of medical practice. Paradoxically, this devaluation of biomedical science is occurring as the ability to use new discoveries to rationalize clinical decision making is rapidly expanding. Understanding the scientific foundations of medical practice and the ability to apply them in the care of patients separates the physician from other health care professionals. The de-emphasis of biomedical science in medical education poses particular dangers for the future of internal medicine as the satisfaction derived from the application of science to the solving of a clinical problem has been a central attraction of the specialty. Internists should be engaged in the ongoing discussions of medical education reform and provide a strong voice in support of rigorous scientific training for the profession.     

Are Internal Medicine Residency Programs Adequately Preparing Physicians to Care for the Baby Boomers? A National Survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P相似文献   

A national survey on the current status of general internal medicine residency education in geriatric medicine

OBJECTIVES: The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs. DESIGN, SETTING, PARTICIPANTS: An original survey was mailed to all the GIM residency directors in the United States (N = 390). RESULTS: A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education. CONCLUSIONS: A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.     

Reforming the core clerkship in internal medicine: the SGIM/CDIM Project. Society of General Internal Medicine/Clerkship Directors in Internal Medicine

Dramatic changes in health care have stimulated reform of undergraduate medical education. In an effort to improve the teaching of generalist competencies and encourage learning in the outpatient setting, the Society of General Internal Medicine joined with the Clerkship Directors in Internal Medicine in a federally sponsored initiative to develop a new curriculum for the internal medicine core clerkship. Using a broad-based advisory committee and working closely with key stakeholders (especially clerkship directors), the project collaborators helped forge a new national consensus on the learning agenda for the clerkship (a prioritized set of basic generalist competencies) and on the proportion of time that should be devoted to outpatient care (at least one third of the clerkship). From this consensus emerged a new curricular model that served as the basis for production of a curriculum guide and faculty resource package. The guide features the prioritized set of basic generalist competencies and specifies the requisite knowledge, skills, and attitudes/values needed to master them, as well as a list of suggested training problems. It also includes recommended training experiences, schedules, and approaches to faculty development, precepting, and student evaluation. Demand for the guide has been strong and led to production of a second edition, which includes additional materials, an electronic version, and a pocket guide for students and faculty. A follow-up survey of clerkship directors administered soon after completion of the first edition revealed widespread use of the curricular guide but also important barriers to full implementation of the new curriculum. Although this collaborative effort appears to have initiated clerkship reform, long-term success will require an enhanced educational infrastructure to support teaching in the outpatient setting.     

Principles to consider in defining new directions in internal medicine training and certification

SGIM endorses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.     

Ambulatory-Based Education in Internal Medicine: Current Organization and Implications for Transformation. Results of A National Survey of Resident Continuity Clinic Directors

BACKGROUND  

Many have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide.     

Primary care internal medicine: a challenging career choice for the 1990s

A career in primary care internal medicine can be challenging and rewarding, yet during the last decade fewer medical students have selected training in internal medicine. We wish to inform medical students, their advisors, and other physicians about the field of primary care internal medicine. We define the discipline, compare it with traditional internal medicine and with family practice, and describe features of strong primary care internal medicine training programs. We discuss common misconceptions and concerns about training programs and the career and give examples of career paths chosen by graduates of primary care programs. We encourage students to consider the option of primary care internal medicine when making career decisions and provide faculty advisors unfamiliar with primary care internal medicine training programs with a reference resource.     

Moving Forward in GME Reform: A 4 + 1 Model of Resident Ambulatory Training

BACKGROUND

Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.

AIM

To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.

SETTING

A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.

PARTICIPANTS

Residents, faculty, and administrative staff.

PROGRAM DESCRIPTION

Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.

PROGRAM EVALUATION

A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased (p = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (p < 0.0001). Satisfaction with ambulatory training improved (p < 0.0001). Self-reported empanelment also increased (p < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (p < 0.0001).

DISCUSSION

A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2387-3) contains supplementary material, which is available to authorized users.KEY WORDS: ambulatory training, 4 + 1 model