Educational Innovation
4:1 Scheduling for Internal Medicine Residents
In 2007, the internal medicine residency program submitted for and was granted an innovation waiver entitled "The Lehigh Valley Schedule: Task-at-Hand Proposal." The request for waiver came out of an acknowledgement for a need to redesign internal medicine training, improve ambulatory education, and limit conflict between clinical rotations and residents' continuity clinic.
Traditional models of residency training emphasize inpatient and subspecialty training and rely on half-day per week continuity clinics to teach ambulatory medicine. Because these clinic sessions occur during, and conflict with, "core" rotations, residents are required to manage responsibilities in multiple clinical arenas. Many residency programs utilize four-week block rotations with continuity clinic sessions occurring a fraction of each week. This model tends to facilitate a disjointed experience, and many residency programs find it difficult to attain the 130 clinic sessions required by the Residency Review Committee for Internal Medicine (RRC-IM). Furthermore, currently the RRC-IM mandates that programs "develop models and schedules for ambulatory training that minimize conflicting inpatient and outpatient responsibilities."
Instead of thirteen four-week blocks, the internal medicine residency implemented a 4:1 scheduling template that alternates traditional four-week rotations with week-long ambulatory blocks. The four-week rotations include standard rotations in internal medicine and non-medicine specialties. The 10 one-week rotations consist of six continuity clinic sessions, one didactic session, and three subspecialty ambulatory experiences. To ensure continuous resident presence in all areas, the residency is divided into five groups (termed "Cohorts A-E"), staggered by one week.
Overall, the new scheduling template was successful in minimizing the conflicts between inpatient and outpatient training, allowing for focused practice during traditional rotations, and providing a stronger focus on ambulatory education. By creating an immersion-type model for outpatient training, the new template provides 180 continuity clinic sessions over three years of training and provides improved educational continuity and continuity of patient care. The internal medicine residency program is now in the 4th year of this innovation. It was the first program in the nation to employ such a template and has been very active in helping numerous programs implement similar templates in their programs. Recent adopters of this system include Tulane University, Temple University, and The University of Missouri. An article describing the innovation was recently published in the Journal of Graduate Medical Education (JGME 2010;2(4):541-547).
Ambulatory Clinic Model
The Ambulatory Curriculum and Continuity Clinic have undergone strong revision over the past five years. Capitalizing on the strengths of the 4:1 schedule, we have restructured how residents provide care to patients in the continuity clinic. Core faculty is dedicated to care for patients in the Lehigh Valley Physicians Practice (LVPP). Our dedicated faculty acts as the primary preceptors of residents in the continuity clinic as well as seeing their own patients alongside the residents. This model has improved patient care, continuity of care, and continuity of learning for the residents. Residents spend their entire three years with the same core faculty person, along with exposure to other models of education from private rotating faculty. This has been extremely well received and effective. Additionally, we have established a true team approach to patient care. With a renewed focus on the team model for patient care and designated weeks in continuity clinic, residents have spear-headed numerous quality and process improvements in LVPP. Residents learn to live the art of continuous quality improvement and develop skills that will help them be successful in future. Our goal is to create a residency ambulatory site that efficiently and effectively provides medical care to an underserved population while at the same time provides a meaningful educational platform for learners.
Coupled with the internal LVPP practice changes, a novel Ambulatory Curriculum has been developed for the residency. This curriculum consists of regular didactics and procedural modules coupled with sessions devoted to videotape review, quality and process improvement, billing and coding, and self-directed learning opportunities. These sessions are facilitated by the core teaching attendings in addition to the private preceptors. An improved expectation and evaluation process has also been developed to include a full-day ambulatory orientation for the interns, a curriculum text and consistent quarterly feedback from preceptors, nursing staff and LVPP administration.
This ambulatory structure is meant to aid in improved focus and dedicated time for ambulatory education, as well as a better outpatient experience and training for our residents.
The Exemplary Care and Learning Site
The concept of an Exemplary Care and Learning Site (ECLS) was born out of the IHI Health Professions Educational Collaborative. Since its beginning, the collaborative has sought to pioneer ways to teach medical students/residents about quality/process improvement. The idea behind the ECLS is to have each site function as a clinical micro-system that incorporates the three aims of improved patient care, improved education and improved system performance. Goals of the ECLS are to help medical (and other) professional students/residents learn about the improvement of healthcare, help foster faculty development, and allow collaboration to speed educational change. In addition to Lehigh Valley Health Network, several institutions have developed their own ECLS programs, including Dartmouth, University of Missouri, University of Minnesota, and the Mayo Clinic.
Construction of a new bed tower and the establishment of geographic admitting for General Internal Medicine teaching services, allowed the ECLS concept become a reality at Lehigh Valley Health Network. In addition to an improved educational focus, a major goal of the ECLS is involvement of the learners in quality improvement efforts. Initial efforts have focused on inpatient glucose control of patients on the ECLS. Such efforts include weekly didactics and collaborative rounds focusing on the nuances of inpatient glucose control. Not only we shown an improvement in medical knowledge, we have seen a dramatic improvement in patient care that has led to over $1,000,00 in cost savings in its first year of operation. Additionally, we have seen improvements in care in other units on which the internal medicine residents rotate. Our data illustrate that experience on the ECLS allows residents to better care for patients throughout the network. Floor data is posted weekly on the floor and residents are provided with individual feedback on the care they are providing to patients. We have also started an infectious disease module on the ECLS to better streamline and reinforce evidence-based guidelines for certain infectious disease.
Procedure Course
All of these endeavors are truly taking the residency program to the next level of educational excellence in clinical training. We are excited to be on this journey of educational innovation and hope you will be interested in joining us!
