|PRACTICAL ADVICE PAPER
|Year : 2022 | Volume
| Issue : 2 | Page : 58-66
Perspectives of internal medicine residency clinics: A national survey of US medical directors
Robert J Fortuna1, Daniel G Tobin2, Halle G Sobel3, Ernie-Paul Barrette4, Craig Noronha5, Larry Laufman6, Xiaofan Huang7, Kristen A Staggers7, Mohan Nadkarni8, Lee B Lu6
1 Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
2 Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
3 Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
4 Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
5 Department of Medicine, Boston University School of Medicine, Boston, MA, USA
6 Department of Medicine, Baylor College of Medicine, Houston, TX, USA
7 Biostatics, Baylor College of Medicine, Houston, TX, USA
8 Department of Medicine, University of Virginia, Charlottesville, VA, USA
|Date of Submission||05-Mar-2022|
|Date of Decision||27-Nov-2022|
|Date of Acceptance||07-Dec-2022|
|Date of Web Publication||12-Jan-2023|
Dr. Robert J Fortuna
Department of Internal Medicine University of Rochester, Rochester, NY
Source of Support: None, Conflict of Interest: None
Background: Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited. Methods: We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US. Results: Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%–20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1–3). For new patient appointments, 34.9% of programs reported a 1–7 day wait and 25.8% reported an 8–14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%–50% for new patients and 11%–25% for established patients. Most programs reported that interns see 3–4 patients per ½-day and senior residents see 5–6 patients per ½-day. Most interns and residents maintain a panel size of 51–120 patients. Discussion: Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.
Keywords: Ambulatory education, medical directors, primary care residency, residency clinic
|How to cite this article:|
Fortuna RJ, Tobin DG, Sobel HG, Barrette EP, Noronha C, Laufman L, Huang X, Staggers KA, Nadkarni M, Lu LB. Perspectives of internal medicine residency clinics: A national survey of US medical directors. Educ Health 2022;35:58-66
|How to cite this URL:|
Fortuna RJ, Tobin DG, Sobel HG, Barrette EP, Noronha C, Laufman L, Huang X, Staggers KA, Nadkarni M, Lu LB. Perspectives of internal medicine residency clinics: A national survey of US medical directors. Educ Health [serial online] 2022 [cited 2023 Mar 28];35:58-66. Available from: https://educationforhealth.net//text.asp?2022/35/2/58/367621
| Background|| |
The ambulatory experience is a cornerstone of internal medicine residency training, yet resident clinics often face many unique hurdles that hinder residents' educational and clinical experiences.,,,, To support programs, the Association of American Medical Colleges (AAMC) has identified building blocks for high performing practices.,,,, Their foundational elements of high performing primary care include engaged leadership, team-based care, patient-team partnership, population management, continuity of care, prompt access to care, and empanelment.,
Implementing these foundational building blocks, however, is frequently challenging in the setting of residency clinics' dual mission to train residents and provide clinical care to patients.,,, Despite the common challenges, programs differ significantly in their operational processes to manage an academic medical practice. For instance, there is a lack of consensus regarding how much protected full-time equivalent (FTE) support should be provided to medical clinic directors, the optimal size of patient panels for residents, the number of patients seen by residents per session, and other operational metrics.,,,,
The Society of General Internal Medicine (SGIM) is an academic society dedicated to “improving access to care for all populations, eliminating health-care disparities, and enhancing medical education.”, Within SGIM, the Medical Residency Clinic Directors Interest Group (MRCDIG) conducts an annual survey of academic medical directors to identify practices used across internal medicine residency programs. We share these operational processes and provide recommendations to serve as a guide for resident clinic directors.
| Methods|| |
We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222). The University of Rochester's Research Subjects Review Board approved the retrospective use of the SGIM MRCDIG survey for research analysis.
Survey development and administration
The survey of medical directors was developed and revised based on the Accreditation Council for Graduate Medical Education requirements and national practice trends., The survey required approximately 20–30 min to complete and was disseminated electronically to all SGIM members in MRCDIG each year before the annual SGIM meeting. The survey was administered using SurveyMonkey®, and 3 reminders were E-mailed to the MRCDIG members 4, 2, and 1 week before the deadline, respectively.
Participants were identified based on an E-mail list maintained by the SGIM. A “medical director” was identified as the physician responsible for managing and directing the physician office. The survey pertained to operational processes within the medical resident clinic, but may have been completed by the medical director, clinic co-director, or residency program director.
The E-mail list was updated annually as medical directors joined or left the MRCDIG. The survey was sent out to between 90 and 119 participants annually from 2015 to 2019. Unique respondent identifiers were not available.
Synthesis of recommendations
Seven experienced medical directors from different programs in the US, each with between 10 and 25 years of experience as a medical director, reviewed the data and synthesized recommendations. After review of the data, unanimous opinions are presented as recommendations.
To provide additional context to sample derivation, we have included annual data for key findings in the Appendix.
| Results|| |
Characteristics of respondents
Between 2015 and 2019, a total of 222 surveys were analyzed [Table 1]. Between 40 and 53 surveys were received per year. Response rates ranged from 43.7% to 50.0%. Programs were largely hospital-based (49.7%) or medical school based (27.0%) and located in an urban setting (73.0%).
|Table 1: Characteristics of programs responding to the survey on operational processes in resident continuity clinics (2015-2019)|
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We found a wide range of protected time provided to the medical director role, but most programs provided 10%–30% FTE support for the position [Table 2]. The amount of support provided for the clinic director role was not associated with the number of residents in the program (P = 0.396).
|Table 2: Full-time equivalent support for clinic director role in residency practices, 2015-2019 (n=179)|
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Patient center medical home structure and operations
At the end of the survey period, the majority of residency programs reported having the National Committee for Quality Assurance patient-centered medical Home (PCMH) certification (level 1–3). PCMH certification tended to increase from 34.2% in 2015% to 52.5% in 2017 and 65.1% in 2019 (P = 0.062).
Access and wait times for appointments
There was a range of responses regarding how far in advance resident clinic schedules/appointments were available. A total of 17.6% of clinics reported that resident schedules were available 1–2 months in advance, 36.3% of programs opened resident schedules 3 months in advance, 27.1% reported schedules were available 4–6 months in advance, and 19.1% opened resident schedules 7–12 months in advance.
We also found a range of average wait times for scheduling an appointment across the programs surveyed, but most programs reported a wait between 2 and 28 days for a new patient visit [Table 3]. Overall, 27.4% of programs reported a wait time for a new patient appointment between 2 and 7 days. We compared the distribution of wait times for an appointment at PCMH certified sites compared to those without PCMH certification [Table 3]. The distribution of reported wait times at PCMH certified clinics compared favorably to non-PCMH clinics for new patients visits (P = 0.029), but was modest or nonsignificant for follow-up and acute appointments.
|Table 3: Length of wait time to appointment in study residency practices (2015-2019)|
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Office visits, visit length, panel size
Most programs reported that interns completed, on average, 3–4 patient visits in a half-day clinic session and senior residents completed 5–6 patient encounters [Figure 1]. Panel sizes for interns and residents were most commonly reported at between 51 and 120 patients.
|Figure 1: Average number of patients seen by resident on ½ day clinic session. Pts: patients|
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We found a range of reported length of office visits between programs. For intern visits with new patients, 1% of programs reported visit lengths of 20 min, 11.5% of programs reported visit lengths of 30 min, 25.5% reported 40 min, and 62.0% reported visit lengths of 60 min. For intern visits with repeat patients, 11.4% of programs reported visit lengths of 20 min, 63.2% of programs reported visit lengths of 30 min, 17.9% reported 40 min, and 7.5% of programs reported 60 min.
For resident (PGY2, 3, 3+) visits with new patients, 1.5% of programs reported visit lengths of 20 min, 23.2% reported visit lengths of 30 min, 37.6% reported 40 min, and 37.6% reported visit lengths of 60 min. For resident visits with repeat patients, 25.9% of programs reported visit lengths of 20 min, 65.5% reported visit lengths of 30 min, 8.6% reported 40 min, and no programs reported visit lengths of 60 min.
Panel sizes for interns and residents were most commonly reported at between 51 and 120 patients.
We found that residency programs reported higher no-show rates for new patients than for established patients (P < 0.001). Among new patients, 5.4% of programs reported that no show rates ranged between 1% and 10%, 36.2% of programs reported no-show rates between 11%–25%, 55.1% reported between 26% and 50% and 3.2% reported rates above 50%. Among established patients, 18.5% of programs reported that no show rates ranged between 1% and 10%, 60.8% of programs reported no-show rates between 11% and 25%, 20.6% reported between 26% and 50%, and no programs reported rates above 50%.
Annual survey data
To explore the influences by year, we examined key findings based on the year of study. Data from individual years are available in the Appendix.
| Discussion|| |
The survey data reveal substantial variability in the operational processes among academic medical practices. Based on the survey results and consensus opinions of the authors, five summary recommendations were made [Table 4].
|Table 4: Summary recommendations on operational processes from survey results and consensus opinion|
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Respondents reported a range of support for the medical director position in academic residency programs, but commonly reported that the position was supported at 11%–30% FTE. The AAMC has established “engaged leadership” as one of the core building blocks for high-performing practices., Although the appropriate amount of dedicated time for the academic medical director is not clearly defined, prior literature describes an extensive list of expectations for this role, requiring a substantial amount of time and institutional commitment., Strong engaged leadership and dedicated outpatient faculty, in turn, are associated with greater resident satisfaction. In addition to improved resident satisfaction, institutional commitment and protected time may allow the clinic director to focus on quality improvement, continuity, and educational initiatives.
Adequate institutional support of ambulatory clinic leadership is a necessary component of successful ambulatory residency training programs. Based on consensus opinion, the authors recommend at least 20% FTE support for the medical director leadership of residency clinics. Additional factors, such as program size, likely impact the “ideal” administrative FTE that should be allocated to the medical director role. We suggest further study to more fully assess how FTE support correlates with perceived medical director performance and office function.
Patient center medical home structure and operations
The overall structure of the residency clinic is crucial to providing effective patient care and resident training. Over the course of the study period, the majority (65.1%) of residency programs reported obtaining PCMH certification (level 1–3). The PCMH is a team-based care delivery model that encompasses five core attributes, including comprehensive care, patient-centered care, coordinated care, accessible services, quality and safety., Although we found that the majority of respondents achieved PCMH certification, those programs still varied widely in their reported operational processes, suggesting that certification alone was insufficient. Prior literature has found that many resident clinics have struggled to translate the PCMH certification into meaningful coordination of care.
Practice transformation and implementation of interprofessional coordinated models of care are important for resident training, but PCMH certification alone is not sufficient. Systems must prioritize the implementation of the underlying values of coordinated models of care to ensure optimal resident training in a multidisciplinary environment. For instance, this may require additional nursing and clerical staff to implement the core values necessary for practice transformation and coordination of care.
Access and wait times for appointments
Despite the variance of responses, many residency clinics in our survey outperformed the nationally reported averages for wait times for an appointment. A 2017 study from Merritt Hawkins found that the mean wait time for a new patient appointment ranged from 24.1 days in large metro markets to 32 days in mid-sized markets. This is encouraging and demonstrates that many residency practices provide timely access to care for the patients they serve. This access is particularly important given that many residency practices are traditionally located in underserved areas.
Residency programs generally provide a high-level of access to care for patients. Given the multiple complexities inherent to residency practices, clinics should be provided the necessary resources to coordinate resident schedules and support access and continuity for patients and ambulatory training for residents. For instance, adequate secretarial and administrative support dedicated to the ambulatory clinic is essential to support resident physician schedules, access for patients, and continuity.
Office visits, visit length
Within any clinic structure, understanding expected clinical volume is important to effectively manage the practice. Visits by resident physicians, however, encapsulate more than a visit by an attending provider by virtue of the training requirements. Overall, the scheduled length of resident visits is greater than national figures for attending physicians, where the average length of a clinical visit was 17.4 min. Justifiably, resident physicians require more time to see patients given their experience level and the educational processes embedded within residency training, including the need to precept each patient with a supervisor.
Resident physicians serve an important role as primary care providers, but expectations for resident clinical volume must take in to account the educational goals and requirements embedded within the ambulatory residency experience. Based on survey responses, training, and clinical needs, the authors recommend visit lengths of at least 20–30 min for follow-up appointments and 40–60 min for new patient appointments. Similarly, the authors recommend that interns see 3–4 patients per session by the end of their intern year, and senior residents see 6 or more patients per session by the end of their training.
Similar to the need to understand expected visits and visit length, it is important to predict no-shows when planning clinic operational processes. Survey responses consistently demonstrated high no-show in residency practices, especially among new patients. Given that many residency practices are located in traditionally underserved areas, there are many social determinants, such as transportation, which influence access to healthcare and no-show rates.,,, To address these challenges, many residency clinics have implemented multi-faceted strategies, such as text message reminders and appointment flexibility. These efforts, however, have demonstrated only modest improvements in no-show rates.,
When planning for anticipated volumes for residency clinics, no-show rates and social determinants must be considered. Given that many residency practices are located in traditionally underserved areas, practices should be supported with the necessary resources, such as social workers, to address the many social determinants which hinder access to medical appointments. This is especially important for new patient visits which have a significantly higher no-show rate than established patient visits.
This study has several limitations. First, we present the results of a convenience sample of medical directors of residency clinics. Although the group of residency medical directors at SGIM represent a broad national sample of academic physician leaders, the sample does not include all programs and may miss community programs. Second, participant identifiers were not available; we could not examine the number of unique programs or link individual respondent data across years. Thus, we had to assume independence of the data for all statistical analyses. The lack of unique identifiers also limits visibility to programs replying across multiple years. To explore the influences by year, we examined key findings based on years of study. The results from individual years yielded similar results to the total and did not influence key conclusions. Third, we were unable to identify differences between respondents versus nonrespondents.
| Conclusion|| |
Creating high-performing residency clinics requires a focus on core building blocks and operational processes. The current survey provides an initial benchmark among academic internal medicine residency clinics. The survey data reveal inconsistent support for the medical director's role and variability in the operational processes among academic medical practices. This suggests that further standardization is needed. Moving forward, it is important for programs to support ambulatory academic medical practices and establish structures that improve clinical care and resident education.
Ethics approval and consent to participate
This study was approved by the Research Subjects Review Board at the University of Rochester.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
Annual data from responding programs related to key findings
| References|| |
Keirns CC, Bosk CL. Perspective: The unintended consequences of training residents in dysfunctional outpatient settings. Acad Med 2008;83:498-502.
Klein R, Alonso S, Anderson C, Vaidya A, Chams N, Kurl A, et al
. Delivering on the promise: Exploring training characteristics and graduate career pursuits of primary care internal medicine residency programs and tracks. J Grad Med Educ 2019;11:447-53.
O'Rourke P, Tseng E, Chacko K, Shalaby M, Cioletti A, Wright S. A national survey of internal medicine primary care residency program directors. J Gen Intern Med 2019;34:1207-12.
Peccoralo LA, Tackett S, Ward L, Federman A, Helenius I, Christmas C, et al
. Resident satisfaction with continuity clinic and career choice in general internal medicine. J Gen Intern Med 2013;28:1020-7.
Babbott SF, Beasley BW, Reddy S, Duffy FD, Nadkarni M, Holmboe ES. Ambulatory office organization for internal medicine resident medical education. Acad Med 2010;85:1880-7.
Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med 2014;12:166-71.
Bodenheimer T, Gupta R, Dubé K, Kong M, Olayiwola JN, Barnes K, et al
. High-Functioning Primary Care Residency Clinics – Building Blocks for Providing Excellent Care and Training. Washington, DC: Association of American Medical Colleges; 2016.
Francis MD, Thomas K, Langan M, Smith A, Drake S, Gwisdalla KL, et al
. Clinic design, key practice metrics, and resident satisfaction in internal medicine continuity clinics: Findings of the educational innovations project ambulatory collaborative. J Grad Med Educ 2014;6:249-55.
Holt SR, Tobin DG, Whitman L, Ellman M, Moriarty JP, Doolittle B. Creating a satisfying continuity clinic experience for primary care trainees. Am J Med 2021;134:547-53.
Bates CK, Yang J, Huang G, Tess AV, Reynolds E, Vanka A, et al
. Separating residents' inpatient and outpatient responsibilities: Improving patient safety, learning environments, and relationships with continuity patients. Acad Med 2016;91:60-4.
Stepczynski J, Holt SR, Ellman MS, Tobin D, Doolittle BR. Factors affecting resident satisfaction in continuity clinic – A systematic review. J Gen Intern Med 2018;33:1386-93.
DeWaters AL, Loria H, Mayo H, Chisty A, Nguyen OK. The impact of block ambulatory scheduling on internal medicine residencies: A systematic review. J Gen Intern Med 2019;34:731-9.
Francis MD, Zahnd WE, Varney A, Scaife SL, Francis ML. Effect of number of clinics and panel size on patient continuity for medical residents. J Grad Med Educ 2009;1:310-5.
Gupta R, Barnes K, Bodenheimer T. Clinic first: 6 actions to Transform ambulatory residency training. J Grad Med Educ 2016;8:500-3.
Wong JG, Fagan M, Pinsker J, Society of General Internal Medicine Medical Resident Clinic Director's Interest Group Consortium. Expectations of and for the medical director of the resident's ambulatory clinic. Am J Med 2001;111:84-7.
HawkinsTeam M. Survey of Physician Appointment Wait Times. Dallas, TX; Merritt Hawkins; 2017.
Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res 2007;42:1871-94.
Braveman P, Egerter S, Williams DR. The social determinants of health: Coming of age. Annu Rev Public Health 2011;32:381-98.
Fiori KP, Heller CG, Rehm CD, Parsons A, Flattau A, Braganza S, et al
. Unmet social needs and no-show visits in primary care in a US Northeastern Urban health system, 2018-2019. Am J Public Health 2020;110:S242-50.
Fortuna RJ, Garfunkel L, Mendoza MD, Ditty M, West J, Nead K, et al
. Factors associated with resident continuity in ambulatory training practices. J Grad Med Educ 2016;8:532-40.
Walker J, Payne B, Clemans-Taylor BL, Snyder ED. Continuity of care in resident outpatient clinics: A scoping review of the literature. J Grad Med Educ 2018;10:16-25.
DuMontier C, Rindfleisch K, Pruszynski J, Frey JJ 3rd
. A multi-method intervention to reduce no-shows in an urban residency clinic. Fam Med 2013;45:634-41.
Junod Perron N, Dao MD, Righini NC, Humair JP, Broers B, Narring F, et al
. Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: A randomized controlled trial. BMC Health Serv Res 2013;13:125.
[Table 1], [Table 2], [Table 3], [Table 4]