The curriculum, submitted to both boards and approved in 1994, was developed to meet the 36-month requirements of both boards. Due to overlap in curriculums, completion for both boards is possible in 48 months as opposed to the 72 months a consecutive approach would require. It was essential during the development of the program that no “short cuts” were taken, but that combined training fulfilled the requirements of both core programs.
The first goal of the combined program was to enhance generalist training. The combined resident rotates on both the Family Practice inpatient service and the General Internal Medicine wards. This allows for precepting on inpatient issues by both family and internal medicine physicians. The combined residents also have continuity care clinics and precepting in both Internal Medicine and Family Practice. The total ambulatory experience is approximately 50% of the residency, as opposed to the ~30% ambulatory requirement of the Internal Medicine program.
Care was taken to avoid disrupting ward responsibilities with this increased ambulatory curriculum. The number of clinics are adjusted based on the intensity of the rotation (i.e. medicine wards vs.consult rotations). Continuity clinics are provided in the family practice residency model clinic for all 4 years. Originally, residents also had Internal Medicine continue in the third and fourth years, but the requirement was recently changed to start in the second year of training. Now the residents spend a day every other week in the Internal Medicine clinic (just as the categorical Internal Medicine residents) alternated with a day-long clinic every other week in the Family Practice model clinic. This gives the residents at least 1 day per week in either Internal Medicine or Family Practice clinic. Residents meet the 24-month continuity care requirement defined by both boards of Internal Medicine and Family Practice.
Care To Differing Communities
Caring for differing communities is a strong aspect of the Ochsner combined program. Ochsner residents serve as primary care physicians for a mixed ethnic, middle-class patient population at the Ochsner's New Orleans East satellite clinic, which is ~95% managed care. Residents also provide longitudinal obstetric and pediatric care at the inner city St. Thomas Clinic providing indigent care.
A rural Family Practice rotation is also included. Residents perform a 1-month rotation through Chabert Medical Center, approximately 30–40 miles from the main Ochsner campus, providing care for an uninsured (and largely Cajun) population. This includes rotations in Internal Medicine, ICU, OB/GYN, and newborn nursery, and provides a community experience as opposed to the tertiary referral experience obtained at the main Ochsner campus.
Efficiency of Training Resources
Program efficiency is improved in several ways. Facilities involve only existing clinics and administrative personnel. The continuity clinics are provided in the existing Family Practice Residency model clinic and one of the Internal Medicine clinics used by the Internal Medicine Residency. In addition, Family Medicine participation in Internal Medicine morning report includes twice-monthly cases presented by the Family Medicine hospital service. Geriatrics lectures are also provided for both Internal Medicine and Family Practice residents once-monthly. Noon conferences and Internal Medicine Grand Rounds are open to all house staff.
Attractiveness of Primary Care
Medical students have found the combined residency attractive, as denoted by a significant number of high-quality students applying and accepting appointments to the residency. Of the original five matching residents appointed to the residency, all completed the residency in June 2000. The program has matched with our highest ranked students over each year of the program despite a marked decline in US graduates entering primary care fields.
Monthly curriculum meetings between the core departments enhance communication on a departmental level. Resident-level interaction on the Internal Medicine ward and consult rotations have also enhanced communication between the departments of Internal and Family Medicine. Combined residents are constantly interacting with residents of both core programs and have fostered more interactions between these residency groups. Both programs' faculty and residents have noted that the combined program has served to improve the core programs from which it derives.
More Role Models
Once several combined residents have completed the residency, they become ideal staff for either medical schools or residency programs of either core program. Their added training is invaluable both in the clinic and on inpatient ward services for either Family or Internal Medicine. We plans to use our graduates as faculty for the combined program in the future. To date, two Ochsner graduates have become staff of the Ochsner Clinic.