Participants:
Yo Kondo, MD (Clinic Director and Core Faculty)
Preston Stephens, MD (R3 Chief Resident)
Jeremy Eaton, DO (APD and Core Faculty)
We often joke among the faculty that any practice/policy/situation no matter how irritating, fantastic or broken that persists for 3 years of training becomes dogma. After all- any resident who was involved in the process that put it in place is long gone. Even those faculty who were not there have forgotten why it exists. As such, at times, it is possible to ignore the giant pink elephant in the room.
Resident continuity may have been the largest pink pachyderm we had. We all know it is an issue. We all know that it is hard. However it had been “just the way it was.”
However, the issue was always there- at the back of our minds. Years ago we attempted to fix the issue. We radically changed the way our 3rd year was structured. Our R3s do 1 week at a time “Rotations” where they spend the majority of their time in the outpatient clinic. This led to 2 outcomes: Increased continuity in the 3rd year AND pushing of inpatient rotations to the R1 and R2 years leading to worsened continuity in those years. I don’t know if this was discussed at the time. It was dogma before any of us were hereJ.
When the opportunity for us to join the Clinic First Collaborative came about we jumped at the chance to explore what it had to offer. For good or bad we also jumped feet first right into the deep end. We made the biggest change to our curriculum since the reworking of our 3rd year those many years ago.
We are committed to separating inpatient experiences from outpatient. It was a radical but simple concept. So why hadn’t we done it before? Because the dogma stated that it was “Good” for residents to have their attention split because that what was happening in the “Real World.” We have a mandate to train residents for rural practice and as such the picture of the small town physician who went to the hospital every morning then to clinic to see patients while at the same time managing inpatients and obstetrical patients persisted. Interestingly when we started looking at regional rural clinics this practice has largely been phased out. Most rural physicians we talked to had a “Hospital
Week” or “Hospital Day” which was shared among a small group of partners. It turns out that they had discovered the same thing the leaders of the collaborative had- it really is not fun to have your brain in 2 places at once.
We accomplished this separation in a couple of ways- we gave the R1s an entire day of outpatient clinic per week with no inpatient duties at all. This effectively doubled the amount of clinic they get in the R1 year. We also switched the R2s to a 2 + 2 format with 2 weeks of a rotation with no clinic followed by 2 weeks of outpatient clinical duties. This increased the R2s clinic time from 4 to 10 days per month of outpatient care.
We really appreciated the symmetry. 4 week rotations for the R1s, 2 weeks for the R2s and 1 week rotations for the R3s. All with progressively more outpatient and less inpatient duties.
The benefits have been obvious. The residents report they are more connected to the clinic. The preceptors state that they feel more connected to the residents. Overall the R2 residents state that they look forward to their clinic weeks. Among them a shift has occurred from having to go to clinic to getting to go to clinic. How about continuity? Well in the first month of the 2+2 format we had a R2 resident near 80% patient perspective continuity. This is double the best we could accomplish last year. A few of the R2s have even made the idea of increased continuity into a competition amongst themselves.
Residents- especially R2s- also seem less frantic. Given the push by the ACGME and others to assess and treat burnout- this curricular change has been a step in the right direction. It appears that we not only have found a way to increase patient continuity but also eliminate a major institutional cause of burnout.
Of course there are both issues that we foresaw and those that we did not. The clinic is absolutely stuffed full at all times. So full in fact that we have had to give occasional admin/work time to residents who could not be fit in.
Our faculty are seeing a ½ day less of their own continuity clinic to make room for the additional residents. Mostly they are spending that time precepting. We averaged between 1-2 preceptors previously in each session with more in the PM session. Now we have at least 2 per session regardless of the time of day. A small portion of the faculty have been vocal in their concerns over less personal clinic time. Many family physicians relate their personal connections to their patients as the way that they stay grounded and avoid burnout. With this change we may be increasing risk for some faculty toward burnout.
We have been working for years to get our schedules out 3 months. In the past year we made great strides toward this. However the more providers in clinic the greater the complexity of scheduling. Hence our schedules have slipped a bit. Likely this will improve as our familiarity with the new system increases.
It still remains to be seen whether total clinic wRVUs have increased. We believe so- but the data is still pending and with less faculty time there is some confounding data to our projections.
The inpatient rotations have also changed. We previously had an R2 inpatient supervisor who helped cover admissions and aided new R1s with the day to day aspects of the inpatient services. This rotation was changed into a medicine “Rover” position which covers for R1 residents so they can be away from the hospital to be in clinic. This has led to inpatient attendings (not employed by the residency) to have to pick up some of these supervisor duties- such as helping with the logistics of EPIC and other aspects of patient care that the R2 supervisor once covered. Many of these attendings have been vocal that they have neither the time nor inclination to sit with a new R1 and help them with a discharge. We have leaned on our R3s for this- however this is an entirely new duty and there have been growing pains trying to get it done seamlessly. We remain at risk of alienating these attendings. It is one of the main concerns we need to remain aware of.
All in all Saint Peter Family Medicine has both embraced and endorsed the changes we have made because of the Clinic First Collaborative. It appears that all involved agree that it has led to more positive than negative changes. We believe that it was the right choice for patients, for education, for resident wellness and likely financially. As for the various growing pains we have been experiencing- perhaps if just wait it out for 3 years?
Our time in Kansas City at the Kickoff Meeting:
Dr. Yo Kondo eating his very first BBQ at Joe's KC: