In the past 20 years, the percentage of required ambulatory training time has increased from 25% to 33% of total clinical exposure,20
and ongoing national discussions highlight the outpatient-inpatient training gap.12
Despite recommendations for more ambulatory training,1–5,12
we were surprised to find that 42% of program directors and 56% of residents favored less
training (i.e., <33% of clinical exposure) in the ambulatory setting. Residents intending to pursue general internal medicine or disciplines that often have a prominent outpatient component (e.g., endocrinology, rheumatology) supported more outpatient training time compared to those planning to pursue inpatient-based careers. Nevertheless, approximately one-third of residents planning careers in geriatrics, rheumatology, general internal medicine, or endocrinology supported less
than 33% ambulatory training time. These data indicate discordance between recommendations of national leaders for expanded outpatient training time and a substantial proportion of residents and program directors who reported counter opinions.
Reasons for this discordance are unclear but worthy of further exploration. Dysfunctions inherent in many resident clinics, including lack of continuity, inadequate information technology, limited support staff, inefficient care systems, and financial constraints21
may negatively affect residents’ and program directors’ attitudes about the quality of this experience. It may be that residents and program directors are reluctant to support additional ambulatory training time unless the dysfunctions prevalent in many resident outpatient clinics are addressed. In addition, because the focus of residency training historically has been in the inpatient setting, innovative and outstanding ambulatory education models may be lacking. A multi-institutional survey of internal medicine residents suggested that residents value their outpatient training experience significantly less than medical ward and intensive care unit rotations.22
Finally, residents and program directors may be influenced by the inability to offset inpatient service demands where residents are often viewed as irreplaceable. As such, they may be responding more from a perspective of work that needs to get done rather than learning that needs to take place.
In our study, the majority of program directors and residents believed that minimizing conflict with inpatient responsibilities was essential for a good outpatient training experience. These perspectives are consistent with prior literature demonstrating that tension between conflicting inpatient and outpatient duties contributes to decreased physician and resident satisfaction.23,24
Residents on inpatient rotations are less likely to start their clinic on time, are more likely to be interrupted in clinic by pages, and are less satisfied with their clinic during busy ward rotations.24
Increased pressure to return to inpatient duties also can impair residents’ ability to focus on their continuity practice,24
and such pressures may compromise reflective observation, inquiry, and feedback, important components of ambulatory learning.25
Patient satisfaction may also suffer when patients are seen by a resident with a larger inpatient clinical workload.26
Residents and program directors clearly reported that the absence of inpatient-outpatient conflict is important for a good outpatient training experience and that weekly clinic during inpatient rotations results in competing inpatient and outpatient responsibilities. Despite these views, the majority of program directors and residents still favored a training model that maintained the presence of a weekly half-day clinic. These conflicting data may highlight the inherent tension between advocating for systems perceived to maintain continuity of care, an important determinant of resident and faculty satisfaction with their outpatient experience,27–30
and the desire to minimize competing inpatient-outpatient responsibilities. Alternatively, these discordant data may reflect forces of inertia in favor of the status quo. Of note, while program directors seemed more concerned than residents about competing inpatient and outpatient responsibilities, they were less supportive of eliminating ambulatory sessions during inpatient rotations. This may reflect program directors’ investment in their current systems, as well as an enhanced understanding of the resources needed for ambulatory redesign and the potential ramifications of redesign initiatives such as reduction in the resident inpatient workforce and graduate medical education funding.
Regardless of preferences for weekly clinic, many program directors and residents supported models that included interspersed or prolonged ambulatory blocks. Little is known, however, about the educational benefits of ambulatory blocks.6,31,32
Increased clinic time can improve continuity between residents and their patients, especially for patients requiring acute care.33
Sufficiently frequent block rotations may also be designed to promote effective delivery of longitudinal continuity care.6
At one institution, a “long block” 12-month continuous ambulatory group-practice experience enhanced resident and patient satisfaction and improved patient outcomes.6
As different models for resident ambulatory training are considered, further outcome-based research assessing patient care and resident educational endpoints should be pursued.
Despite being one of the largest national studies capturing internal medicine residents’ and program directors’ opinions about ambulatory training, there are several important limitations. We did not ask residents or program directors about the current structure or quality of ambulatory training at their institution, and, as such, were unable to determine how their current training environment influenced their perceptions. Similarly, we did not collect demographic information on program directors to know whether gender, age, or subspecialty training affected attitudes. University or community-based program status was not determined, and we were thus unable to compare responses based on this variable. Since we only used quantitative methods, we were unable to collect more nuanced information about program directors’ and residents’ perspectives, and we do not know the reasons behind their preferences. Finally, there is likely a variance in how some residents and program directors define continuity or access that would influence the choice of models for education in ambulatory care. Our response rate for both program directors and residents, though acceptable, raises the possibility of response bias.
In conclusion, this study describes residents’ and program directors’ attitudes about ambulatory training during internal medicine residency, views that are important to consider in the midst of ongoing national discussions of ambulatory training redesign. Continued work is needed to understand the discordance between residents’ and program directors’ preferences about outpatient training duration and national recommendations for increased ambulatory training time. Furthermore, research is needed to understand program directors’ and residents’ beliefs about the benefits and barriers to ambulatory redesign and their reluctance to endorse models that minimize inpatient-outpatient conflicts. Innovation and study of the benefits and drawbacks of alternative models and venues for ambulatory training are needed. As new models for ambulatory training are piloted, medical educators and researchers should use this as an opportunity to further explore the impact on outpatient case-mix, resident-patient-preceptor continuity and satisfaction, and learner educational and patient outcomes.