Alternative approaches to ambulatory training: internal medicine residents' and program directors' perspectives.

Abstract

BACKGROUND: Internal medicine ambulatory training redesign, including recommendations to increase ambulatory training, is a focus of national discussion. Residents' and program directors' perceptions about ambulatory training models are unknown. OBJECTIVE: To describe internal medicine residents' and program directors' perceptions regarding ambulatory training duration, alternative ambulatory training models, and factors important for ambulatory education. DESIGN: National cohort study. PARTICIPANTS: Internal medicine residents (N = 14,941) and program directors (N = 222) who completed the 2007 Internal Medicine In-Training Examination (IM-ITE) Residents Questionnaire or Program Directors Survey, representing 389 US residency programs. RESULTS: A total of 58.4% of program directors and 43.7% of residents preferred one-third or more training time in outpatient settings. Resident preferences for one-third or more outpatient training increased with higher levels of training (48.3% PGY3), female sex (52.7%), primary care program enrollment (64.8%), and anticipated outpatient-focused career, such as geriatrics. Most program directors (77.3%) and residents (58.4%) preferred training models containing weekly clinic. Although residents and program directors reported problems with competing inpatient-outpatient responsibilities (74.9% and 88.1%, respectively) and felt that absence of conflict with inpatient responsibilities is important for good outpatient training (69.4% and 74.2%, respectively), only 41.6% of residents and 22.7% of program directors supported models eliminating ambulatory sessions during inpatient rotations. CONCLUSIONS: Residents' and program directors' preferences for outpatient training differ from recommendations for increased ambulatory training. Discordance was observed between reported problems with conflicting inpatient-outpatient responsibilities and preferences for models maintaining longitudinal clinic during inpatient rotations. Further study regarding benefits and barriers of ambulatory redesign is needed.