The Case

A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty concentrating. The symptoms began after a motor vehicle collision a week earlier. She tried to schedule the visit with her primary care doctor—a resident—but his available slots were already full. This was not unusual—his availability was often limited to one clinic session per week due to his inpatient clinical obligations. Therefore, the appointment was booked with another resident provider.

During the clinic visit, the patient relayed the events of the collision to the resident. She reported that she had been sitting in the backseat, wearing her seatbelt, and that the impact caused her to strike her head on the window. Immediately after, she had been taken to a local emergency department for evaluation. Physical examination and head imaging were unremarkable, and the patient was discharged home. She subsequently developed headaches and difficulty concentrating as well as sensitivity to sound and light. The resident diagnosed probable postconcussive syndrome and started the patient on amitriptyline.

Given a lack of improvement in her symptoms, the patient returned to the same clinic 4 days later. Again, her primary provider was not available to see her. The resident who had seen her initially was no longer on his outpatient rotation, and the appointment was booked with a different resident provider. This resident ordered a brain MRI and placed a referral for the patient to be seen in neurology clinic. The resident had never placed a subspecialty referral before and did not realize that there were multiple neurology clinics. When the patient arrived at the neurology appointment several days later, she was informed that the referral had been made to the neuromuscular clinic though it should have been made to the headache clinic.

The patient returned to the internal medicine clinic for a third time because she was still experiencing severe headaches. This time she was able to see her assigned primary care provider. Although she was frustrated by the lack of continuity and incorrect neurology referral, the patient repeated in detail the same history she had relayed to the first and second resident providers. Her primary provider increased the dose of her amitriptyline and placed a new neurology referral to the headache clinic. The patient's headaches improved, and she was feeling much better by the time she saw the neurologist.

The Commentary

by Eric Warm, MD

The landmark 2002 paper, Medical Professionalism in the New Millennium: A Physician Charter, states that, "Changes in the health care delivery systems in countries throughout the industrial world threaten the values of professionalism."(1) The authors list technology, market forces, globalization, and even bioterrorism as changes to be addressed, and they direct physicians to recommit to honesty, confidentiality, trust, and other professional virtues to counteract these forces. The case described above illustrates the challenges associated with training residents while simultaneously meeting the needs of patients. What could the residents in the case possibly have done to better demonstrate professional excellence?

Will Durant, discussing Artistotle, once wrote, "We do not act rightly because we have virtue or excellence, but we rather have these because we have acted rightly; we are what we repeatedly do."(2) Shortly after the Physician Charter was written, Hafferty and Castellani, harkening back to Aristotle, began examining the question of professionalism with that end in mind.(3) In our case, the patient received poorly executed, poorly coordinated, and poorly supervised care. Lapses in professionalism were not secondary to negligent acts on the part of the residents, but the result of a system that places both residents and patients in suboptimal positions. As Lesser and colleagues wrote, "professional behaviors are profoundly influenced by the organizational and environmental context of contemporary medical practice."(4) Medical students may come to residency with noble goals, but training programs force them to adopt behaviors at odds with these initial impulses. A new and sobering body of research shows that practice patterns developed in residency persist many years after training ends.(5)

There are significant challenges associated with educating residents in ambulatory care. Many contemporary academic leaders trained in a time when ambulatory education received marginal financial and organizational support. The outpatient experience was chaotic, characterized by complex patients with overwhelming social issues. Team-based care was nonexistent. Making matters worse, the model of a half-day per week of outpatient clinic embedded within inpatient training, the typical structure, guaranteed frequent and sometimes dangerous discontinuities for many patients. The dysfunctional nature of ambulatory training became the expected norm. Few patient care or educational outcome studies have been done to formally evaluate this type of ambulatory education, but the available evidence suggests that it was of limited educational value to trainees and created a system that facilitated poor clinical performance.(6) Internal data from our own residency program revealed that patients of residents who were on an all-consuming intensive care unit rotation in December were significantly less likely to receive an annual flu shot. In addition, for residents planning a cardiology career, the chance that their patients received pap smears in the resident clinic approached zero (unpublished data). Under the traditional model of ambulatory care, patients in our residents' practice received care of a quality that fell significantly below reasonable national standards.(7)

After the Accreditation Council for Graduate Medical Education duty hour changes of 2003 and 2011, training programs were forced to rethink trainees' ambulatory schedules. Several common models emerged to challenge the standard half-day per week ambulatory sessions, including short block models of alternating inpatient and outpatient time (e.g., 4 inpatient weeks followed by 1 outpatient week or 6 inpatient weeks followed by 2 outpatient weeks), and longer, immersive outpatient experiences.

The evidence base regarding the best model for ambulatory education is limited, and at times conflicting. Block models and immersive models successfully minimize conflict across inpatient and outpatient care settings without sacrificing overall resident satisfaction or resident perception of continuity.(7,8) Contact with the same physician (as reflected in the number of visits in the previous 12 months) is positively associated with improved quality of care.(9) In one study, block programs demonstrated greater continuity from the patient perspective.(10) However, in other studies, immersive experiences performed better than shorter block models.(7,11) In a recent study at one academic medical center, separating residents' inpatient and outpatient responsibilities was associated with improved resident perception of patient safety, the learning environment, and resident–patient relationships, but no actual patient outcomes data were collected.(12) Although studies of varied models demonstrate improvement in patient care outcomes and satisfaction, it is not clear which components of a given model are most important for achieving these.(7)

Gupta and colleagues recently performed site visits and a qualitative analysis of 23 family medicine, internal medicine, and pediatric residency teaching clinics.(13) In this work, they expanded on Bodenheimer's previously described 10 aspects of high-performing care (engaged leadership, data-driven improvement, team-based care, patient–team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and the template of the future).(13,14) They found high-performing training practices were creative with resident scheduling, finding ways to balance residents' inpatient and outpatient obligations to increase continuity.(13) High-performing programs also had high levels of resident engagement, with residents serving as primary drivers of care transformation.

It is clear that for many residents and the patients they serve, the organization of training practices is an important determinant of outcomes. There is evidence that continuity in care, a dedicated ambulatory curriculum, and appropriate outpatient supervision are key guiding principles for ambulatory education reform.(15) The diverse nature and goals of academic training environments make it impossible, and in fact undesirable, to create a single standard for outpatient education. Instead, we should define standards for the most important aspects of outpatient training and find ways to measure meaningful outcomes. Only then can we assign accountability within the system and redesign processes to further improve.

In this case, the patient saw a different provider in each of her three visits. Sometimes it is appropriate to emphasize access over continuity, but it does not appear the patient was given a choice. If she had to see different physicians, then the team should have had reliable handover processes in place as well as better consistency with attending physician supervision, or both. The second resident who saw the patient committed an error in the referral process, likely due to a lack of experience and supervision. High-performing practices would not accept errors of this type, and they would systematically work to understand and eliminate them. This understanding could be accomplished during weekly interprofessional team meetings designed to review errors as they occur.(16) Ideally, the resident who made the error and the supervising attending would drive this process. Everyone in the practice, including residents, attendings, nurses, and staff, are accountable for performance. Frequent measurement and sharing of data are first steps to achieving a culture of shared responsibility for patient care.

The expectations of residents serving as primary care providers should be the same as those of all physicians—to meet the needs of the patients. Emerging evidence suggests that meaningfully separating the inpatient from outpatient responsibilities of trainees is a necessary but not sufficient element toward achieving better ambulatory education and improved patient outcomes. High-performing practices must also measure care outcomes and engage residents and all team members in the improvement process.

Take-Home Points

• Residents cannot be expected to properly balance inpatient and outpatient obligations unless the underlying structure of training allows them to do so.
• Residency programs should develop ambulatory training experiences using continuity as an organizing principle, which generally will require separating inpatient and outpatient duties to a significant degree.
• Ambulatory training practices should measure the effects of structure on patient care outcomes and develop interprofessional teams to improve care.
• Residents should have a central role in analyzing and improving these processes.

Eric Warm, MD Richard W. & Sue P. Vilter Professor of Medicine Program Director, Internal Medicine University of Cincinnati Academic Health Center

References

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