The Financial Cost of Interprofessional Ambulatory Training: What's the Bottom Line?

ABSTRACT Background Team-based care is recommended as a building block of high-performing primary care but has not been widely adapted in training sites. Cost may be one barrier to a team-based approach. Objective We quantified incremental annual faculty and staff costs as well as potential cost savings associated with an interprofessional (IP) ambulatory training program compared to a traditional residency clinic at the same site. Methods Cost calculations for the 2017–2018 academic year were made using US Department of Labor median salaries by profession and divided by the number of residents trained per year. Cost implications of lower no-show rates were calculated by multiplying the difference in no-show rate by the number of scheduled appointments, and then by the weighted average of the reimbursement rate. Results A total of 1572 arrived appointments were seen by the 10 residents in the IP program compared with 8689 arrived appointments seen by 57 residents in the traditional clinic. The no-show rate was 11.5% (265 of 2311) in the IP program and 19.2% (2532 of 13 154) in the traditional clinic (P < .001). Total cost to the health system through higher staffing needs was $113,897, or $11,390 per trained resident. Conclusions Total costs of the IP model due to higher faculty and staff to resident ratios totaled $11,390 per resident per year. Understanding the faculty and staff costs and potential cost-saving opportunities associated with transformation to an IP model may assist in sustainability.

Enhanced Ambulatory Electronic Health Record Training for Residents: Prospective Cohort Study. (Preprint)

BACKGROUND Physicians spend a significant amount of time with Electronic Health Record (EHR) systems but receive inadequate training. Prior studies have shown benefit from intern orientation programs such as “boot camps” for clinical knowledge or skills but few have examined courses for enhanced EHR orientation. OBJECTIVE To improve EHR clinic workflow processes and assess the impact of a structured course on intern confidence and preparedness. METHODS One faculty and two resident physicians spent approximately 30 hours creating a four-hour course curriculum, which was taught to a group of incoming Internal Medicine interns in June and July 2017. The interns completed a course feedback survey along with self-reported outpatient EHR workflow process confidence surveys at 1, 6, and 12 months. A control group also completed the same confidence surveys at the same intervals. RESULTS A total of 15 out of 18 Internal Medicine interns (83%) took the course. All 15 reported they learned useful information and had increased overall confidence. A majority (93%) agreed the course would allow them to provide better care for their patients and that the course content was best delivered by a physician. Most interns (80%) agreed the course should be a required part of internship. Confidence scores in eight major workflow areas significantly increased after the course and persisted throughout intern year. A control group of interns had low initial confidence scores that increased at 6 and 12 months. CONCLUSIONS A 4-hour targeted EHR ambulatory training course was feasible, highly rated, and increased workflow confidence scores for the first 6 months.

EPAs for the Ambulatory Internist in Translation: Findings from a Canadian Multi-Center Survey

Background Increased demand for outpatient care has made defining the role of ambulatory general internists an educational priority. Canadian residency programs are transitioning towards competency-based education, where learning goals are articulated as entrustable professional activities (EPAs). Engaging frontline internists in the validation of context-specific EPAs is important for implementation. Objective This study describes a consensus approach for developing EPAs for ambulatory general internal medicine (GIM) training and results of a Canada-wide survey seeking feedback from academic internists. Methods In 2016, we reviewed Royal College of Physicians and Surgeons of Canada GIM accreditation documents, and systematic literature search results for internal medicine ambulatory training objectives, to draft EPAs. EPAs were revised via expert consensus at the University of Toronto. A survey was distributed to Canadian academic internists to determine level of agreement on proposed EPAs. Consensus was defined as greater than 80% inter-rater agreement. Open-ended questions explored reasons for disagreements, which were reviewed independently by authors and iteratively organized into categories. Results Eight EPAs were generated. Survey response rate was 24.9% (63/253). Consensus was achieved on all EPAs except obstetrical medicine (49/63, 77.8%). Reasons for disagreements reflected variable understanding of EPA concepts by respondents. Where understood well, disagreements fell into 3 main categories: (1) further training required, (2) not within internal medicine scope, and (3) implementation barriers. Conclusions Frontline academic physicians are pivotal in validating proposed EPAs. Disagreements were either content or concept related and recognizing these diverse perspectives can help clinician-educators predict and prepare for challenges with EPA implementation.

Delivering on the Promise: Exploring Training Characteristics and Graduate Career Pursuits of Primary Care Internal Medicine Residency Programs and Tracks

ABSTRACT Background Specialized primary care internal medicine (PC IM) residency programs and tracks aim to provide dedicated PC training. How programs deliver this is unclear. Objective We explored how PC IM programs and tracks provide ambulatory training. Methods We conducted a cross-sectional survey from 2012 to 2013 of PC IM program and track leaders via a search of national databases and program websites. We reported PC IM curricular content, clinical experiences, and graduate career pursuits, and assessed correlation between career pursuits and curricular content and clinical experiences. Results Forty-five of 70 (64%) identified PC IM programs and tracks completed the survey. PC IM programs provide a breadth of curricular content and clinical experiences, including a mean 22.8 weeks ambulatory training and a mean 69.4 continuity clinics per year. Of PC IM graduates within 5 years, 55.8% pursue PC or general internal medicine (GIM) careers and 23.1% pursue traditional subspecialty fellowship training. Curricular content and clinical experiences correlate weakly with career choices. PC IM graduates pursuing PC or GIM careers correlated with ambulatory rotation in women's health (correlation coefficient [rho] = 0.36, P = .034) and mental health (rho = 0.38, P = .023) and curricular content in teaching and medical education (rho = 0.35, P = .035). PC IM graduates pursuing subspecialty fellowship negatively correlated with curricular content in leadership and teams (rho = -0.48, P = .003) and ambulatory training time (rho = -0.38, P = .024). Conclusions PC IM programs and tracks largely deliver on the promise to provide PC training and education and produce graduates engaged in PC and GIM.

Ambulatory Training Program to Expand Procedural Skills in Primary Care

Introduction: Outpatient procedures are an important component of primary care, yet few programs incorporate procedural training into their curriculum. We examined a 4-year procedural curriculum to improve understanding of ambulatory procedures and increase the number of procedures performed. Methods: A total of 56 resident and 8 faculty physicians participated in a procedural curriculum directed at joint injections (knee, shoulder, elbow, trochanteric bursa, carpal tunnel, wrist, and ankle), subdermal contraceptive insertion/removal, skin biopsies, and ultrasound use in primary care. We administered annual surveys and used generalized estimating equations to model changes. Results: Across the 4 years, there was an average 96% response rate. Mean comfort level with the indications for procedures increased for both resident (62.5 to 78.8; P < .0001) and faculty physicians (61.5 to 94.8; P < .0001). Similarly, mean comfort with performing procedures increased for both resident (32.1 to 62.3; P < .0001) and faculty physicians (42.2 to 85.4; P < .0001). Residents’ comfort level performing procedures increased for all individual procedures measured. The mean number of procedures performed per year increased for resident (1.9 to 8.2; P < .0001) and faculty physicians (14.7 to 25.2; P = .087). Conclusions: A longitudinal ambulatory-based procedural curriculum can increase resident and faculty physician understanding and comfort performing primary-care-based procedures. This, in turn, increased the total number of procedures performed.