Residency Update – The New “4 + 1” Schedule Template
- By Mark Levine, MD
This academic year the residency instituted a new schedule that allows residents to completely separate inpatient and ambulatory responsibilities. This is partially in response to an ACGME mandate that residencies develop models and schedules for ambulatory training that accomplish that goal. Through this change we hope to enhance the educational and clinical experience in all settings.
The schedule follows a 4 + 1 template: Four weeks of a dedicated rotation (occasionally two 2 week rotations) followed by one week of ambulatory medicine. The ambulatory medicine week is comprised of continuity clinic along with experiences in subspecialty medicine ambulatory settings. The continuity clinic component of the week varies between 40% and 60%. There are two half days dedicated to ambulatory education. During Tuesday morning core sessions a comprehensive curriculum in ambulatory general internal medicine is covered spanning chronic disease management, evaluation of acute episodic conditions, screening and prevention, and communication skills. Friday morning sessions are devoted to practice management and quality improvement opportunities. Currently for these sessions our residents are participating an ABIM Practice Improvement Module dealing with screening and prevention and through a total quality management process they are seeking to improve the quality of care of the resident clinic population. Finally, 30%-40% of these weeks are available for longitudinal ambulatory subspecialty medicine experiences and our current areas of focus include endocrinology, rheumatology, and geriatrics.
Our expectations were quite high that numerous aspects of the residency experience and education would improve, and this has indeed occurred. Residents appreciate the fact that there are no long stretches of call months, as there is always an ambulatory week after four weeks of inpatient experience, thus reducing potential for resident fatigue. They especially appreciate the lack of conflict in “getting to clinic”, always a source of tension when one must leave a busy inpatient service. The longitudinal primary care experience has substantially improved. The opportunity to develop a firm system with one attending and several residents enhances learning and continuity of care even on weeks when patients arrive and their primary resident is not in clinic. Improvements in scheduling and continuity for patients with their residents have followed. The ambulatory education curriculum is a highlight of the experience. Residents learn what it is like to practice in a highly functioning outpatient setting incorporating a patient-centered medical home (our resident clinic is NCQA approved). There are opportunities for quality improvement projects and improved panel management. The longitudinal subspecialty experiences, while successful, need to be further optimized by having residents spend more time per week in a specific specialty and consolidate their exposure and education in that manner. Finally, the care of patients in the inpatient setting has also benefited as team members are no longer rushing off to clinic.
There are still abundant opportunities for this scheduling template to further improve the overall educational experience of residents. Our focus over the next academic year will be:
1) Continue efforts to improve teaching in the inpatient setting and pursue additional initiatives for enhanced bedside teaching experiences.
2) Continue to develop elective opportunities for primary care track residents (and categorical residents who are interested) as the 4 + 1 system has clearly rejuvenated the educational experience in the primary care setting and the attractiveness of that career path.
3) Pursue the above consolidation of subspecialty medicine experiences.
4) Work with subspecialty faculty to develop new educational models, including interactive web-based curricula that will serve resident education well as some of the specialty exposures move away from the traditional one month block to a more longitudinal format.