Redesigning residency: New models for internal medicine programs

Educators experiment with ways to improve physician training and patient care.

By Myrle Croasdale — Posted Oct. 23, 2006

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With residents' training compressed into 80 hours a week, it's becoming increasing clear there are flaws in the system. There has to be a way, educators say, to improve both physician training and patient care. And, there should be a way to allow programs to draw on their own strengths and use different methods to achieve those goals.

To encourage this structural overhaul, the Accreditation Council for Graduate Medical Education established the Educational Innovations Project.

In March, 17 internal medicine programs were selected to prepare new models, that, if successful, could be replicated by other institutions.

Here are three examples:

Idea: Geographic teams.
Goal: No more running floor to floor.
School: Beth Israel Deconess Medical Center, Boston.

Private physicians with patients at Beth Israel Deaconess Medical Center, one of Harvard Medical School's teaching affiliates, may get a pleasant surprise when they do rounds. If a doctor's patient is being treated by the general medicine department, the admitting intern or resident is likely to be right there to answer questions.

That's the direct benefit of a new system the hospital implemented July 1. Unlike in most big teaching hospitals, internal medicine residents here are assigned to a specific floor, with all their patients in the same unit. Residents get new patients only when a bed on their floor opens up.

Educators say the new system gives residents the chance to get to know a unit's nurses and case managers and makes them more available.

"Before, we were incessantly paged," said Scott Woodman, MD, PhD, a third-year resident.

Under the old system, for example, a case manager screening a patient before discharge would try to determine which rehabilitation facility would be the most appropriate, but a question would arise about why the patient was on a particular medication. The physical therapist would have a question about the patient being unsteady on his feet, and the case manager also needed to know if the patient should be on oxygen at the nursing home.

"You get a page from the case manager about the oxygen, the nurse calls about the meds, which you're unsure about because you have to look at the chart. The physical therapist asks you about the difference in the patient's walking ability, and you haven't rounded with the patient yet," Dr. Woodman said.

Meanwhile, Dr. Woodman said he easily could have had four other patients on four different floors. He would have been paged three times for this single patient and would have had to come down to that floor at least once.

"Now I'm on the same floor, so I don't have that," he said.

Julius Yang, MD, assistant internal medicine program director, said that, in a way, they're returning to the old ward rotations.

"The purpose is not only to have the physician present, adjacent to the patient, but to improve teamwork among health care providers," Dr. Yang said. "You can't learn advanced team skills unless you form teams."

With the nurses, residents, medical students, case workers and social workers all on the same floor, communication is continuous, relationships develop and more feedback occurs.

It also provides a chance to collect more meaningful data on patient outcomes, Dr. Yang said. Instead of just hospitalwide statistics on mortality, hospital-acquired infections, patient satisfaction and the like, the new structure allows them to collect these data by patient team or floor. That gives the front-line staff a chance to identify areas that need improvement and make changes.

The goal is to have each patient's length of stay, infection status and other quality indicators in the electronic medical record system on what they're calling an electronic dashboard. The information on each patient will be just a click away.

The end result should be a less intimidating atmosphere for patients, and one where care is coordinated and outcomes improve.

"We hope that patients will tell us this is a better system," Dr. Yang said.

Idea: Blocks of time.
Goal: No more interruptions.
School: University of Cincinnati Academic Health Center.

Innovation at the internal medicine program at the University of Cincinnati Academic Health Center revolves around eliminating the tradition of residents handling inpatient care while trying to squeeze in a half day of outpatient clinic each week.

"The patients hated it. They could never see their doctors. And the residents hated it," said Eric J. Warm, MD, associate internal medicine program director.

Jagdeep Singh, MD, a second-year resident, agreed. "The continuity isn't there."

Under the new structure, scheduled to begin in November, second-year residents will spend 3½ days a week in the ambulatory clinic. The rest of their time will be spent on elective rotations.

The clinic will be run like a regular practice. If the patient's resident physician isn't there, one member of a team of two or three residents will cover.

The idea is to give residents a realistic experience of primary care and a chance to focus on ambulatory training without the burden of inpatients.

Dr. Warm said this schedule allows for "burst continuity." When a heart failure patient is stable, for example, any physician can handle the check-up, but if this patient has an acute illness, he or she needs a burst of visits to get the situation under control.

Dr. Warm also expects the schedule to reduce the number of hospital admissions for the resident practice, which has been running twice that of the faculty practice.

In addition, residents will have a day of protected educational time each week to learn how to assess and improve care. Topics will include common problems such as diabetes or coronary heart disease.

The block is intended to allow residents the opportunity to invest in a string of electives outside of clinic that will help them focus their careers. Dr. Singh is using his electives to help decide whether to seek a fellowship.

"I'm interested in cardiology and internal medicine," Dr. Singh said. "This long block allows us to chose our own destiny."

Idea: 16-hour call shifts.
Goal: No more sleep walking.
School: Summa Health System/Northeastern Ohio Universities College of Medicine.

Overnight call for internal medicine residents at Ohio's Akron City Hospital dropped in 2005 from the mandatory 30-hour limit to 24 hours. In July, the hours dropped again, and physicians in training now take call for only 16 hours.

Thomas Brown, MD, a third-year resident, has experienced all three variations.

"Instead of dreading a call coming up ... we have these [shorter] calls, and they don't wear us down," he said.

Call on the notoriously hectic intensive care unit has been pruned even further -- to 12 hours.

"You do a lot of good, and you don't get burned out," Dr. Brown said.

The new schedule means he has call more frequently, five to six times a month compared with two to three before. Overall, though, he likes the change.

"Residency is like a marathon, and you don't want to sprint, then have to keep going," he said.

David B. Sweet, MD, internal medicine residency director, said implementing a 16-hour call structure was common sense after sleep studies by the Harvard Work Hours, Health and Safety Group showed that residents who worked 24 continuous hours were at greater risk for making medical errors than those who worked a maximum of 16 hours on call.

The Ohio program added teaching rounds to the night shift. Residents do two months on the night float team, and some faculty have been hired to work at night.

Buy-in from faculty and residents was the hardest part, Dr. Sweet said. But stable faculty leadership and support from administrators helped unify the physician faculty and residents.

"Faculty are working harder," he said, "And you'll have some saying that [residents working fewer hours] isn't as good, but you look at the trade-off."

The Harvard sleep studies found that sleep deprivation is an impairment, saying a resident who has worked a series of 24-hour shifts is functioning at the same level as if he or she were legally drunk. "I'd never send a resident to see a patient after having two drinks," Dr. Sweet said.

Dr. Brown said he works an average 67 hours a week, which means he misses a few noon conferences. But, he said, it also means he's more alert for the ones he does attend. "With less fatigue throughout the month. We're able to pick up more while we're awake."

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Trying something new

The ACGME's Educational Innovations Project challenged internal medicine resident programs to develop new systems that foster high-quality care and competency-based education. Here are some emerging themes:

  • Higher quality education linked to higher quality health care.
  • Education and health care delivered based on what's best for the patient, rather than on the priorities of insurance companies, hospitals or even the doctors.
  • Clinical microsystems set up so health professionals work as a team and team-based care is incorporated into every-day tasks.
  • Quality improvements and outcome measurement skills integrated into training. For example, residents track in-hospital infection rates for their patients and help devise ways to lower them.
  • Ambulatory and in-hospital care kept as separate blocks of time.
  • Simulation labs used to better prepare interns for bedside encounters.
  • Web-based portfolios created to document such things as projects residents have worked on, original research papers and letters of recommendation.
  • New measurement tools introduced for the six competencies: patient care, medical knowledge, practice-based learning, professionalism, system-based practice, and interpersonal and communication skills.

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External links

Accreditation Council for Graduate Medical Education's Educational Innovations Project proposals (link)

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