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Objective: Market and technology innovations have greatly changed the teaching and practice of medicine in the past 10 years. This report describes an innovation in the ambulatory education of internal medicine residents: a subspecialty continuity clinic. Methods: A subspecialty continuity clinic was developed to improve the training of internal medicine residents in caring for complex ambulatory patients. The clinic structure is discussed from the perspective of patients, residents, and subspecialists. Logistical challenges and solutions are described. Results: Two and one-half years into the program, feedback from residents and subspecialists has been positive. In-training examination scores are relatively higher in the involved specialties, and residents are managing illnesses they rarely saw in an outpatient setting before this program. Conclusion: This experience suggests that a subspecialty continuity clinic is worthwhile and practical in educating primary care residents.

Introduction

ne dilemma facing internal medicine residency program directors is how to provide education in both general and subspecialty internal medicine. Leaders in medical education have been calling for more unity of subspecialty and primary care internal medicine. '2 A survey of Associates of the American College of Physicians in 1997 suggested that young internists are concerned that the distinction between family medicine and internal medicine is becoming blurred and also that more training in subspecialty medicine might make general internal medicine a more attractive career choice.3

Simultaneously, contemporary medical care and education have shifted to the outpatient arena.4 A recent survey by Swing and Vasilias showed that most teaching of continuity care occurs in general internal medicine practices associated with tertiary medical centers.5 Residents on elective rotations in subspecialty clinics are usually exposed to only a "snapshot" of an individual patient's condition. This may not allow observation of disease progression or therapeutic responses in diseases classically managed by subspecialists. Is there a way for training programs to provide education in the continuity care for patients managed by subspecialists? In some settings, especially in the military, general internists are responsible for integrating and providing care previously provided by their subspecialty colleagues.

To improve our residents' experiences with patients traditionally followed by subspecialists, we developed a program designed to focus on continuity care from the perspective of a subspecialist. This Resident Subspecialty Continuity Clinic (RSCC) is described below.

Methods

Study Site

Madigan Army Medical Center is a community-based teaching hospital and tertiary care referral center that manages more than 1 million outpatient visits annually. Nine internal medicine residents graduate each year, and our medical center supports several other residencies. In addition to inpatient rotations, our residents rotate for 1-month outpatient rotations in each of the disciplines of internal medicine. Residents also serve for onehalf day per week in a continuity primary care clinic (about 44 weeks per year). Residents are responsible for the primary care of 60 to 90 patients, depending on their level of training. Our residents follow some patients in the primary care clinic who see subspecialists within our department for acute and chronic diseases. For example, a resident might provide primary care for a patient with rheumatoid arthritis while a rheumatologist administers and monitors the cytotoxic drugs. Similar situations occur for patients with human immunodeficiency virus (HIS, cancer, degenerative neurologic diseases, and chronic renal failure.

At our department retreat 3 years ago, the RSCC was proposed as a way for residents to participate in the longitudinal care of patients from a subspecialist perspective. As its name suggests, the RSCC provides an opportunity for residents to follow patients with direct subspecialist supervision for an extended time. The sections below describe the clinic design and observations we have made in the 2.5 years since the clinic's inception.

Clinic Design

Patient Perspective

The RSCC clinic enrolls patients through three different pathways. Patients can be referred from a resident's own primary care panel, followed up from a ward or subspecialty rotation, or be assigned to interested residents by the subspecialty clinic.

In the first pathway, residents use the RSCC to obtain subspecialist consultation for their own primary care patients. For example, a patient in a resident's panel who develops Grave's disease may initially see her primary physician (the resident) in our primary care clinic. She may then follow up with the same resident and an endocrinologist in the RSCC endocrinology clinic. The resident participates in the entire diagnostic and therapeutic process with the patient and has the expertise of a subspecialist physician preceptor. Another patient with endstage renal disease and severe congestive heart failure could meet with the resident in the nephrology clinic one week and in the cardiology clinic another week. This provides subspecialty care for the patient while maintaining unique continuity for the patient and teaching for the resident.

Second, patients can enroll in the RSCC for follow-up after an encounter on a subspecialty or ward rotation. A patient seen during the last week of a pulmonary rotation can follow up to discuss test results with the resident and pulmonologist after the resident ends the typical 1-month rotation. Patients evaluated in the emergency room or admitted by the resident can also be followed through the appropriate subspecialty clinic in the RSCC.

In the third pathway, we may assign residents a limited number of subspecialty patients. Our subspecialists select patients with appropriate diseases for the clinic and refer them to the RSCC coordinator. The resident can then assume the continuing role of subspecialty consultant without necessarily assuming the patient's primary care.

Resident Perspective

The RSCC format was proposed and developed with input from residents. The RSCC is not found in one location but could be defined as "what medicine residents do on Monday afternoons." Residents participate on Monday afternoons except during intensive care unit rotations, rotations at outside hospitals, and when on call or post call. Each resident has three 1-hour slots available. On a given day, a resident might see one patient in the hematology clinic at 1 p.m., another patient in the nephrology clinic at 2 p.m., and a third patient in the infectious diseases clinic at 3 p.m. One-hour appointments are usually enough time to see a patient, provide the patient with appropriate teaching, and get to the next clinic. Residents are reminded which clinic to go to each week through an e-mail message sent out on the preceding Thursday.

Subspect/ist Perspective

Currently, appointments are booked in nephrology, endocrinology, infectious diseases, cardiology, neurology, pulmonary, hematology/oncology, gastroenterology, rheumatology, dermatology, gynecology, and psychiatry clinics. Each clinic has three 1-hour slots available, which are often filled by three different residents. The e-mail message sent to residents by our administrative assistant also goes to each clinic, so that clerks and staff physicians know which patients to expect. Some of the subspecialists see their own patients in the afternoon as well, scheduling them between the RSCC patients. Some of the subspecialists spend the afternoon on administrative duties in addition to supervising the care of the three scheduled RSCC patients. Each subspecialty clinic has developed its own policy to balance productivity for the clinic and teaching for the residents.

Scheduling

Arranging the appointments was initially difficult. After a year of decentralization, we began scheduling patients through a dedicated administrative assistant. This assistant takes phone calls from residents or patients and keeps simultaneous clinic and resident schedules. This system is separate from our usual scheduling, but it works well and takes less then 5 hours per week of administrative time. When a resident assigned to a given patient is unavailable, the patient is given the option of seeing another resident designated as a surrogate or seeing the subspecialist directly.

Results

Patient Feedback

Although we have not surveyed patients directly, it seems that their satisfaction is excellent and that the quality of care has improved. A patient seen in the primary care clinic can be seen in a subspecialty clinic within less than I week. This greatly exceeds the access standard for most of our subspecialty clinics. The real benefit for patients comes from continuity, and it is difficult to estimate how much time is saved and how much care is improved by seeing the same provider in multiple settings. Again, although we have not surveyed patients formally, we have many anecdotal testimonies of satisfaction and no complaints in the past 2 years of scheduling almost 2,000 patient visits. Examples of currently managed chronic diseases are listed in Table I.

Resident Feedback

Four graduates of our program have written unsolicited letters praising the RSCC, and one said that it was "the single best thing about the residency." An informal survey of the last two graduating classes showed that our residents found the clinic enjoyable and educational. Graduates in both academic fellowships and community hospitals have informed us that the clinic experience was *very useful" to them in their new jobs.

The current residents also enjoy the clinic, and several current residents have described it as "the best part of our residency." They have used the clinic to explore subspecialty careers, close knowledge gaps, and enhance procedural skills. Residents interested in a subspecialty career are free to follow as many patients in a particular discipline as they desire. One of our residents interested in nephrology is currently following four renal transplant patients. A resident interested in infectious diseases follows four patients with HIV. Residents have occasionally grouped four or five flexible sigmoidoscopy appointments for their primary care patients into one afternoon, enhancing their procedural skill and improving clinic efficiency. Residents have been able to perform endometrial, liver, renal, thyroid, lung, and skin biopsies on their own primary care patients through this clinic. These are opportunities previously less available or unavailable for our residents.

For the first 2 years, this was an entirely voluntary program. This year, the RSCC director is providing specific information to the program director about individual resident participation. Although the clinic is still voluntary, residents are aware that the extent to which they participate in the clinic is being reported to their supervisors. Participation increased from about 60% to 100% of our residents when this feedback was given.

Subspecialist Feedback

Our subspecialists enjoy the clinic. Although some subspecialty staff initially had reservations about the idea, it has proven to be an innovative way for them to teach about disease management. We ask each of the staff members involved how the clinic is operating at least twice a year, and feedback is positive. Some of the subspecialists feel that the clinic gives them a chance to improve efficiency, although this is not a universal feeling. All of them enjoy the chance to interact with residents without the artificial constraints of 1-month rotations.

One area that needed improvement was feedback for residents. Currently, residents see patients with one-on-one staff oversight and receive immediate feedback on performance. Because residents see patients in so many different clinics, accountability is diffuse and it is difficult to provide the residency director with timely specific feedback about each resident. We experimented with having formal logbooks kept for each session, but residents found this bulky and intrusive. Currently, feedback in the clinic consists of a running tally of the total number of patients seen and informal discussions of performance.

Problems

As mentioned above, initially the clinic faced several logistic challenges. Having each clinic schedule its own patients in our computer system seemed easy in theory but required lots of coordination in practice. Centralized scheduling made it easier for the patients, the residents, and the clinics involved.

Certain diseases and patients did not easily fit into the clinic format. For example, patients with flares of inflammatory bowel disease often needed to be seen on the day symptoms began rather then waiting for a weekly clinic. Also, the RSCC initially seemed to be a good way to see more adolescent patients through our hospital's adolescent clinic. Unfortunately, adolescent patients often are unable or unwilling to come to a clinic scheduled only once a week for routine health care issues.

Initially, only four of our subspecialty clinics agreed to participate. This was actually helpful because our scheduling problems affected fewer patients. It took a full year for us to centralize and for all of the other clinics to feel comfortable enough with the concept to participate.

Educational Objectives

The primary objectives of this clinic were to increase residents' ambulatory care and subspecialty exposure. This clinic has doubled resident continuity clinic exposure from about 44 half-day sessions per year to approximately 78. All of our residents now graduate having longitudinally followed patients with HIV, renal failure, and chronic neurologic problems with direct oversight by a subspecialist.. Before this clinic, almost none of our residents had this experience.

We studied our residents' in-training examination scores for our program before and after starting this clinic. In-training program performance reports demonstrate that the four subspecialty clinics that have seen the largest number of RSCC patients have increased mean correct scores from 1.6% (1 and 2 years before RSCC inception) to 3.4% (1 and 2 years after RSCC inception) above the all-program mean percentile. In contrast, our residents' performance in the four subspecialties that have seen the smallest number of RSCC patients have decreased mean correct scores from 4.75% to 4.0% above the all-program average for the same period. Admittedly, we have had resident and faculty turnover during this period in all subspecialties, and there are many other factors not controlled for in these statistics.

Discussion

The RSCC is inherently flexible, and it has helped us with some of the challenges of teaching medicine in the outpatient arena. The RSCC has the potential to increase resident knowledge about common disorders traditionally managed by subspecialists. It allows residents to observe disease progression, to monitor response to or toxicity of therapy, and to better understand the work of the subspecialist consultant.

The relationships between generalists and specialists are complex and important, and the ability to appreciate both sides of this interaction is a critical skill for all physicians.6 These skills are particularly useful in a military environment, in which primary care physicians are often responsible for the health of patients in remote locations. We believe that these skills are also useful for other primary care physicians, such as family practice and pediatric specialists. A recent editorial in the Annals of Internal Medicine states that internists must "rediscover the common ground between the general internist and the internistsubspecialist."7 We think this clinic is a good start.

Acknowledgment

The authors acknowledge Chris Wiitanen, without whom the Resident Subspecialty Continuity Clinic would not be possible.

References

1. Association of Subspecialty Professors: Training in subspecialty medicine: on the chessboard of health care reform. Ann Intern Med 1994; 121: 810-3.

2. Kelley WN: Primary care and subspecialty medicine: fostering a unified internal medicine. J Gen Intern Med 1992; 7: 221-4.

3. Salerno SM, Cowl CO: The opinion of current and recent internal medicine residents regarding a fourth year of training and the future of general internal medicine. Am J Med 1997; 102: 143-6.

4. Rabkin MT: A paradigm shift in academic medicine? Acad Med 1998; 73: 127-31.

5.Swing SR, Vasilias J: Internal medicine residency education in ambulatory settings. Acad Med 1997: 72: 988-96.

6. Pearson SD: Principles of generalist-specialist relationships. J Gen Intern Med 1999; 14(suppl 1): S13-20.

7. Nolan JP: Internal medicine in the current health care environment: a need for reaffirmation. Ann Intern Med 1998; 128: 857-62.

Guarantor: MAJ Daniel C. Randall, MC USA

Contributors: MAJ Daniel C. Randall, MC USA; Jeffrey Strong, MD; MAJ Robert Gibbons, MC USA

Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA. The opinions or assertions contained in this article are the private views of the

authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.

This manuscript was received for review in June 1999. The revised manuscript was accepted for publication in February 2000.

Reprint & Copyright by Association of Military Surgeons of U.S., 2001.

Copyright Association of Military Surgeons of the United States Jan 2001
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