Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe

In Canada, graduates of internal medicine training programs should be proficient in ambulatory medicine and practice. Before determining how to improve education in ambulatory care, a list of desired learning outcomes must be identified and used as the foundation for the design, implementation and evaluation of instructional events. The Delphi technique is a qualitative-research method that uses a series of questionnaires sent to a group of experts with controlled feedback provided by the researchers after each round of questions. A modified Delphi technique was used to determine the competencies required for an ambulatory care curriculum based on the CanMEDS roles. Four groups deemed to be critical stakeholders in residency education were invited to take part in this study: 1. Medical educators and planners, 2. Members of the Canadian Society of Internal Medicine (CSIM), 3. Recent Royal College certificants in internal medicine, 4. Residents currently in core internal medicine residency programs. Panelists were sent questionnaires asking them to rate learning outcomes based on their importance to residency training in ambulatory care. Four hundred and nineteen participants completed the round 1 questionnaire that was comprised of 75 topics identified through a literature search. Using predefined criteria for degree of importance and consensus, 19 items were included in the compendium and 9 were excluded after one round. Forty-two items for which the panel that did not reach consensus, as well as 3 new items suggested by the panel were included in the questionnaire for round 2. Two hundred and forty participants completed the round 2 questionnaire; consensus was reached for each of the 45 items. After two rounds, 21 items were included in the final compendium as very high priority topics (“must be able to”). An additional 26 items were identified as high priority topics (“should be able to”). The overall ratings by each of the four groups were similar and there were no differences between groups that affected the selection of items for the final compendium. To our knowledge this is the first time a Delphi-process has been used to determine the content of an ambulatory care curriculum in internal medicine in Canada. The compendium could potentially be used as the basis to structure training programs in ambulatory care. Barker LR. Curriculum for Ambulatory Care Training in Medical residency: rationale, attitudes and generic proficiencies. J Gen Intern Med 1990; 5(supp.):S3-S14. Levinsky NG. A survey of changes in the proportions of ambulatory training in internal medicine clerkships and residencies from 1986-87 to 1996-97. Acad Med 1998; 73:1114-1115. Linn LS, Brook RH, Clarke VA, Fink A, Kosecoff J. Evaluation of ambulatory care training by graduates of internal medicine residencies. J Med Educ 1986; 61:293-302.

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An Ambulatory Clinical Teaching Unit: Filling the Outpatient Gap in Internal Medicine Residency Training

Canadian Journal of General Internal Medicine ◽

10.22374/cjgim.v11i3.148 ◽

2016 ◽

Vol 11 (3) ◽

Author(s):

Mohamed Panju MSc MD ◽

Ali Kara MD ◽

Akbar Panju MB ◽

Martha Fulford MD ◽

Paul O'Bryne MB ◽

...

Keyword(s):

Internal Medicine ◽

Royal College ◽

Clinical Teaching ◽

Formal Structure ◽

General Internist ◽

Clinical Environment ◽

Educational Curriculum ◽

General Internal ◽

Ambulatory Medicine ◽

Teaching Unit

The majority of time in a core General Internal Medicine (GIM) residency is spent focusing on inpatient medicine, with relatively little time devoted to ambulatory medicine. The Royal College of Physicians and Surgeons of Canada has mandated an improvement in ambulatory exposure. Unfortunately, most ambulatory experiences tend to lack formal structure, a dedicated educational curriculum, and graduated learner-specific responsibilities. The recent Royal College recognition of GIM as a subspecialty places renewed emphasis on core IM training providing a more comprehensive exposure to outpatient medicine as management of patients with multiple complex conditions may be best managed by a general internist. In July 2015, McMaster University opened an outpatient medicine clinic which is designed to be an Ambulatory Clinical Teaching Unit (A-CTU). The A-CTU provides a structured clinical environment which is focused on the management of medically-complex patients. It uses a multidisciplinary model, graded learner levels of responsibility and a dedicated educational curriculum. The unique structure of the A-CTU allows for the assessment of milestones and EPAs (entrustable professional activities) pertaining to consultation skills and chronic disease management, in keeping with competence by design.

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Comprehensive ambulatory medicine training for categorical internal medicine residents

Journal of General Internal Medicine ◽

10.1046/j.1525-1497.2003.20712.x ◽

2003 ◽

Vol 18 (4) ◽

pp. 288-293 ◽

Cited By ~ 9

Author(s):

Monica Bharel ◽

Sharad Jain ◽

Harry Hollander

Keyword(s):

Internal Medicine ◽

Internal Medicine Residents ◽

Ambulatory Medicine

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The 4∶1 Schedule: A Novel Template for Internal Medicine Residencies

Journal of Graduate Medical Education ◽

10.4300/jgme-d-10-00044.1 ◽

2010 ◽

Vol 2 (4) ◽

pp. 541-547 ◽

Cited By ~ 38

Author(s):

Jennifer L. Mariotti ◽

Marc Shalaby ◽

John P. Fitzgibbons

Keyword(s):

Internal Medicine ◽

Primary Care Physicians ◽

Present System ◽

Internal Medicine Training ◽

Continuity Clinic ◽

Ambulatory Training ◽

Immersion Experience ◽

Before And After ◽

Ambulatory Medicine ◽

Ambulatory Education

Abstract Background It is widely acknowledged that there is need for redesign of internal medicine training. Duty hour restrictions, an increasing focus on patient safety, the possibility of inadequate training in ambulatory care, and a growing shortage of primary care physicians are some factors that fuel this redesign movement. Intervention We implemented a 4∶1 scheduling template that alternates traditional 4-week rotations with week-long ambulatory blocks. Annually, this provides 10 blocks of traditional rotations without continuity clinic sessions and 10 weeks of ambulatory experience without inpatient responsibilities. To ensure continuous resident presence in all areas, residents are divided into 5 groups, each staggered by 1 week. Evaluation We surveyed residents and faculty before and after the intervention, with questions focused on attitudes toward ambulatory medicine and training. We also conducted focus groups with independent groups of residents and faculty, designed to assess the benefits and drawbacks of the new scheduling template and to identify areas for future improvement. Results Overall, the scheduling template minimized the conflicts between inpatient and outpatient training, promoted a stronger emphasis on ambulatory education, allowed for focused practice during traditional rotations, and enhanced perceptions of team development. By creating an immersion experience in ambulatory training, the template allowed up to 180 continuity clinic sessions during 3 years of training and provided improved educational continuity and continuity of patient care. Conclusion Separating inpatient and ambulatory education allows for enhanced modeling of the evolving practice of internists and removes some of the conflict inherent in the present system.

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The Historical Development of Burden of Treatment Compliance

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2014.sepoct02 ◽

2014 ◽

Vol 19 (5) ◽

pp. 13-15

Author(s):

Stephen L. Demeter

Keyword(s):

Internal Medicine ◽

Treatment Compliance ◽

World Health ◽

International Classification Of Functioning ◽

Sixth Edition ◽

Burden Of Treatment ◽

Specific Goal ◽

Surrogate Measure ◽

Health Organization

Abstract A long-standing criticism of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) has been the inequity between the internal medicine ratings and the orthopedic ratings; in the comparison, internal medicine ratings appear inflated. A specific goal of the AMA Guides, Sixth Edition, was to diminish, where possible, those disparities. This led to the use of the International Classification of Functioning, Disability, and Health from the World Health Organization in the AMA Guides, Sixth Edition, including the addition of the burden of treatment compliance (BOTC). The BOTC originally was intended to allow rating internal medicine conditions using the types and numbers of medications as a surrogate measure of the severity of a condition when other, more traditional methods, did not exist or were insufficient. Internal medicine relies on step-wise escalation of treatment, and BOTC usefully provides an estimate of impairment based on the need to be compliant with treatment. Simplistically, the need to take more medications may indicate a greater impairment burden. BOTC is introduced in the first chapter of the AMA Guides, Sixth Edition, which clarifies that “BOTC refers to the impairment that results from adhering to a complex regimen of medications, testing, and/or procedures to achieve an objective, measurable, clinical improvement that would not occur, or potentially could be reversed, in the absence of compliance.

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