Sudeep Kaur Aulakh

Training the ambulatory internist: rebalancing residency education

doctor time and attention for patient care. What was tried? Initial improvements included switching to an electronic medical record (EMR)based written handover and creating a standard format for verbal handover. However, we inconsistently applied the template and handover sessions continued to vary in content and length. Based on resident-driven discussions, we then designed a system of peer observation and feedback to help identify and address common pitfalls in applying our standard format. Once weekly, an off-service resident observed handover, evaluated the team using a standardised instrument, and provided 1–2 minutes of direct feedback, including at least one strength and at least one area for improvement. We trained residents in providing feedback and using the feedback instrument during a 45-minute conference. We also provided materials online for later reference. Residents evaluated these changes and our overall handover competence as a group before and after the 4month period of peer feedback. Residents also tracked time spent in sign-out per patient each day during the implementation of these changes. What lessons were learned? The standard format and weekly peer feedback improved resident ratings of our programme’s overall competence in handover, with 35% and 77%, respectively, of residents rating our competence at 4 or 5 on a 5-point Likert scale before and after these changes. All residents felt comfortable receiving and providing peer feedback, and agreed with the statements: ‘It did not affect the sign-out environment and felt collegial’ and ‘I felt comfortable and appropriate giving both positive and negative feedback.’ Most residents also felt that receiving and providing peer feedback was useful, and agreed with the statements: ‘Feedback was specific, organised, and has positively affected my sign-out skill’ and ‘I feel my feedback will improve my own and the team’s future signouts.’ About half of the residents were able to recall feedback they had either received or provided. Samples of peer feedback include: ‘Quiet sign-out with minimal interruptions, good question and answer at end of each patient. Recommend working on clear patient status (i.e. sick patients) and clear if/then/because statements’ and ‘Good use of “if x, then y”. Perhaps don’t need to give all details – ex. “patient had extensive out-patient workup for weight loss” instead of listing every test. Ideally, night team would read that information.’ The standard format also decreased the average time spent in handover; however, peer feedback alone had no additional impact on the length of handover sessions. Given residents’ positive responses to this intervention, peer feedback may represent an innovative tool for improvement. Residents in our programme have identified other areas to be targeted in the future, including the peer review of written communication skills.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine

T o the EditorWe wholeheartedly agree with Stanley et. al. about how the residency experience seems to dissuade residents from pursuing primary care careers, and agree that graduate medical education reform is imperative. As the authors describe, there are many reasons why this is the case. Training programs overwhelmingly favor hospital-based rotations, with outpatient medicine typically representing not more than one-third of training time. Simply increasing ambulatory time does not address the challenges that discourage residents from pursuing primary care careers. Additionally, many residency clinics provide care to socioeconomically disadvantaged patients with complex needs. Expecting trainees to be confident and fully engaged in ambulatory care with our current training models is unrealistic. We have designed a primary care training program to address these challenges, with >50 % of the training in the ambulatory environment. To prepare primary care residents for complex disease management in an ambulatory setting, our residents participate in year-long longitudinal subspecialty ambulatory electives with subspecialty preceptors, as opposed to hospital-based subspecialty electives. These subspecialty preceptors have become resources for our residents, allowing them to experience the importance of teamwork and collaboration in primary care. We have implemented a second primary care continuity site to expose residents to diverse patient populations and ambulatory environments. To preserve the passion for advocacy that residents possess, we have integrated a community project into our program. Protected time allows residents to pursue advocacy projects of their choice. Examples of projects include a Spanish/English language and cultural exchange program, a high school nutrition curriculum, promoting health education in a homeless shelter and volunteering services to a local free clinic. Each self-selected project helps to keep our residents grounded in what initially attracted them to primary care. Mentorship is an essential feature of our program. Just as residents are encouraged to pursue subspecialty careers, it is equally important to enthusiastically encourage primary care careers. Quarterly get-togethers with the primary care codirectors are instrumental in maintaining engagement. During these dinners, we discuss medical, political and cultural issues in primary care, facilitate dialogue about career goals and promote peer group mentoring. We have graduated two classes of primary care residents to date, and 80 % of our graduates have pursued primary care careers. Additionally, several categorical residents have transferred into our program, while none of the primary care residents have left. We believe that continued innovation and mentorship will help to successfully build and maintain resident interest in primary care.