I became program director in July 2017 and one of my top priorities was to improve our residents’ clinical experience. Too frequently I heard our residents remark about how strong we were in inpatient while stating how much they disliked clinic. They felt like they never knew the patients on their schedules, didn’t have enough time to complete notes or paperwork before rushing off to their next assignment, and felt the nurses and staff weren’t very helpful. I chose family medicine after spending my third-year medical clerkship with a family medicine physician who knew his patients, had great support from his staff, and ran an efficient clinic. Why couldn’t we offer that same experience to our residents? How were we really going to recruit more medical students into family medicine at our university if rotated in an inefficient residency clinic full of disgruntled residents?
The concept of making the family medicine center (FMC) the cornerstone of family medicine training is not new. However, I do think there are a variety of ways to make this happen. As an academic residency program that works alongside a number of our residency programs, the mini-block schedule was very intriguing to me. I remember feeling rushed as a resident spending a half day in clinic and the other half day elsewhere. I remember putting off clinic notes and paperwork because it felt like inpatient was more pressing. The idea of being fully immersed in clinic for 2 weeks each month sounded like a great idea. After getting home from the Clinic First Collaborative kick off meeting in February, I shared the information with my faculty and residents and they agreed!
We implemented the mini-block this past July for our PGY 2 and PGY 3s. Our interns still do the traditional 4 week blocks with 1-2 half days of clinic each week. Thus far the resident response has been positive overall. They like being in the same location all day and having weeks that are pretty predictable as far as scheduling goes. While it’s still early, the general consensus is that they are seeing more of their own patients, so continuity is going up from the provider standpoint. The other services we rotate with were happy with this schedule because it meant I was no longer pulling my residents from clinic. This meant they had more freedom to fully incorporate my residents into their services and teams. I’ve been able to give each resident a half day of admin during their 2 week clinic block, and we’ve been able to incorporate a population health longitudinal assignment that provides protected time to focus on panel management while developing their QI skills.
Of course there are always challenges! The negative feedback I’ve gotten is that residents are always in clinic with the same group of people. The previous schedule changed their clinic days each month, so you always interacted with different residents. They all still get together for didactics once a week, but they don’t see some residents as frequently as they once did. The other gripe has been that elective time has been decreased. While we still provide more elective time than required by the RC, it is less than it once was, and this has been an adjustment. Previously our residents ran out of ideas of what to do with their elective time and now they use it more wisely. We will continue to watch this and try to find other options for elective time as we go forward.
Overall, I think the new schedule that emphasizes the clinic experience has been positively received and we have appreciated being a part of the Clinic First Collaborative. Our patient access and clinical numbers are up. Residents are getting to know their panels of patients better and appreciate protected time for administrative tasks and QI. Since no rotation is longer than 2 weeks for my PGY 2 and 3s, they do not look as exhausted after difficult rotations in the ICU or on night float. We will continue tracking numbers and collecting resident and patient data to determine how this schedule impacts all stakeholders, but we are optimistic that this new schedule will take us one step closer to providing and exceptional clinical experience!