Do we have a problem?

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1 Building a Better Mousetrap: Innovations in Primary Care Training Kerri Palamara Michael Rosenblum Donna Windish APDIM Spring 2014 Meeting Nashville, Tennessee Do we have a problem?

2 Archives of Internal Medicine April 2011 Senior medical students from 1990 (1,244) and 2007 (1,177). Primary care medicine as a reason for entering internal medicine fell from 57% to 33%. 41% of the 2007 respondents said the primary care aspect of GIM pushed them away from the field, compared to 21% in Those choosing to practice GIM in 2007 fell from 9% to 2%. Students felt that internal medicine involved a heavier workload and more stress. 80% of internal medicine categorical residents subspecialize (AAFP) Where Have All the Primary Care Doctors Gone? Almost half the residents in a 50,000 person survey who began their training wanting to become primary care doctors changed their minds. By the time residency was finished, only one out of five wanted to become primary care physicians. Pauline Chen, MD, NYT

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4 2013 Match Medicine-Primary Number of Positions 335 (1999: 575 positions) Number Filled 331 U.S. Senior 200 Osteopathic 17 U.S. IMG 50 IMG 61 Unfilled slots 4 Medicine-Categorical: 6,277 positions Results and Data 2013 Main Residency Match

5 What can (and what should) WE do about it?

6 Baystate Innovations The Problems Tension between inpatient and outpatient rotations Inpatient >> Ambulatory Fragmented continuity in the clinic Poor understanding of the PCP s role Developing broad skills to avoid referrals Our Solutions 2 week alternating block schedule Longitudinal elective experiences for PC residents Baystate Medical Center 659 beds, established 1883 Springfield, MA Community academic program/tufts 54 Categorical IM residents 12 Primary Care residents 32 Med Peds residents 10 residencies/16 fellowships Original EIP program 2006

7 We like to blow things up!! Demographics Springfield, Massachusetts 49,000 visits annually 48% Spanish Speaking Medicare: 29.8% Medicaid: 23.4% Managed Medicaid): 30.6% High Prevalence of Chronic Illnesses -Diabetes: 23% of patients Ranked 14 of 14 for mortality and morbidity, SE factors NCQA PCMH 2011 Standards Level 3 Hours Providers Monday and Friday 8am-5pm/ Tue-Thu 8 AM- 8 PM 47 categorical medicine residents/ 8 Primary care residents 6 full-time NP/PA (8 direct PC sessions, 2 Admin) 11 part-time Faculty (1.0 FTE: 6 direct PC, 2 admin, 2 Precepting) 10 Provider teams + specialty clinics Hybrid model of ambulatory blocks and continuity days

8 Primary Care Residency HRSA grant (ends 2015) Up to 4 residents/year Mission: train residents through a balance of supervision and autonomy to provide effective, efficient, equitable and patientcentered care. 14 Day Alternating Mini-Blocks 14 Traditional Day Alternating and New Mini Models -Blocks OLD Block 1 (28D) Manager (M) 2 Ambulatory (A) 3 CCU (28D) NEW 1A 1B 2A 2B 3 (14D) M A M A CCU

9 Resident Comments Questions (abridged): N=10 (max) Selected Comments Which type of schedule do you prefer? 90% Miniblocks Better focus on wards and clinic, better time management. Improves learning and overall satisfaction. Opportunity for follow up? 80% prefer Mini-blocks I can see my patient in the clinic, give 3-4 weeks appointment, do 2 weeks of manager and then see the patient again in the clinic. I like that. What effect has the new schedule had on your fatigue level? 60% less fatigue 40% same level 0% more You don t get fatigue, you can think about your hospital pt w/o thinking or worrying about your outpatient it improves outside hospital life with your family/so/loved ones How satisfied are you with the new scheduling model and its impact on your ambulatory training? 90% more satisfied I enjoy having more primary care patient panels when I'm at clinic. I find it less stressful than squeezing in clinic during inpatient. Overall, how satisfied are you with your ambulatory care experience? 1-5 Scale Average= 3.5 Overall this has been a GREAT change in the program. It has increased the ability to focus on care, not get exhausted and learn more. I have learned more ambulatory medicine, I feel better prepared for out pt medicine now.

10 PC Rotation Structure First 6 blocks: orientation and core rotations Next 30 blocks: alternating 2 week ambulatory and inpatient experiences to maximize continuity BLOCK 1 BLOCK 2 BLOCK 3 BLOCK 4 BLOCK 5 BLOCK 6 BLOCK 7 BLOCK 8 BLOCK 9 BLOCK 10 BLOCK 11 BLOCK 12 YEAR 1 ORIENT ATION WARDS ICU / NF ED/ WARDS/ CCU ED/NF CCU/ WARDS / WARDS / WARDS YEAR 2 WARDS/ WARDS/ QUALITY/ CONSULT WARDS/ / CCU /NF / WARDS /NF / CICU YEAR 3 CONSULT/A MB / WARDS / WARDS ADMIT/ / ADMIT ICU/ ICU/ WARDS/ / CONSULT A Week in the Life of a PC Resident BLOCK 12 / WARDS

11 Outcomes Increased engagement in managing ambulatory patients Networking with elective preceptors Home visits PC residents focus on continuous, dynamic process of healthcare Advocacy (community projects) PC jealousy! The Resident Experience

12 Lessons Learned Maintaining continuity during continuity electives Faculty development Scheduling challenges Next Steps Qualitative measurement PC: Cat Long term outcomes for PC residents Community of Practice Ambulatory Chief Resident

13 Yale Primary Care Program (YPC) Donna Windish, MD, MPH Associate Program Director YPC Program Demographics 50 Residents 3 Residents PC/HIV track 3 Residents PC/VA Center of Excellence track No Outside/HRSA funding

14 Primary Care Program History Established in 1989 First graduating class 1992 Over 100 graduates of the residency work in Connecticut 70% of whom are in general internal medicine (academics, practice and hospitalists) Move community training site to New Haven July 2014 Educational Philosophy al Training Didactic Curriculum Role of Core Faculty Meeting Individual Goals

15 Educational Philosophy al Training Align clinical sites of training with educational goals of the experience Inpatient Training Mix of General Medicine and Subspecialty Rotations General Medicine Rotations at the St. Raphael Campus Primary Care, Community Hospital Environment Subspecialty Medicine Rotations at the York Street Campus Subspecialty, Referral and Tertiary Care Hospital environment Longitudinal Primary Care Training Faculty/Resident Practices Yale Primary Care Residency Ambulatory Care Center VA Center of Excellence in Primary Care Nathan Smith HIV for trainees in the HIV Primary Care Track Community Based General Medicine Training Primary Care Practices Outpatient Subspecialty Training University and Community Based Practices International Health Fully Funded Global Health Program West Haven VA VA grant primary care education COE Patient centered medical home (PACT) Continuity clinic and ambulatory blocks at West Haven VA Inter professional learning Educational domains Sustained relationships Shared decision making Performance improvement

16 Educational Philosophy Didactic Curriculum All the usual suspects Morning Report Core s Firm s Grand Rounds Morbidity and Mortality Professors Rounds YPC Special Didactics Ambulatory Fridays Biostats Curriculum Evidence Based Medicine Curriculum Physical Exam Curriculum Yale Office Based Medicine Curriculum Educational Philosophy Role of Core Faculty To advise, mentor, guide and inspire the housestaff Continuity practice preceptors General medicine ward attendings Research advisors for many residents Primary academic advisors for all residents Curriculum development, implementation and evaluation Local, regional, and national leaders in medical education

17 Educational Philosophy Individual Goals Assist each resident in finding their most rewarding niche in medicine Academic Advising and Career Mentoring Individually Tailored Electives Advocacy Education (goal of creating an education track) Research Rotation Selection Specific subspecialty services Range of general medicine services Wide range of ambulatory training settings Educational Innovation Day Night Teaching Teams Geographically Localized True Day and Night Team Structure No day floats, night floats or holdovers Evening overlap and transiti0n of care from day team to night team Morning overlap and transiti0n of care from night team to day team One Hour Firm Rounds every morning, all team members including attendings, with bedside presentation of admissions and warm handoff of patients

18 Rotation Schedule number of weeks per experience PGY I PGY II PGY III Inpatient 26 weeks 22 weeks 18 weeks Outpatient 16 weeks 18 weeks 20 weeks Flexible 4 weeks 6 weeks 8 weeks No true 4x4, but working on it. Still do ambulatory continuity practice during 2 of 4 weeks on the wards Working on decreasing the number of ICU blocks Intern Ambulatory Blocks (18 20 weeks) Immersion (4 wk) Immersion (4 wk) Immersion/QI (2 wk) Neuro Selective (2 wk) Yale ED (2 wk) Geriatrics (4 wk)

19 Sample Intern Block Block Intern A Intern B Schedule 1 CCU Neuro/Vacation 2 Neuro/Vacation Floors York 3 Floors York Ambulatory A 4 Ambulatory A Floors SRC 5 Floors SRC Jeop/Elective 6 Jeop/Elective MICU 7 Floors/ED ED/Floors 8 MICU Geriatrics 9 Geriatrics Floors SRC 10 Floors SRC Ambulatory B 11 Ambulatory B Floors York 12 Floors York Vacation/Amb QI 13 Vacation/Amb QI CCU PGY2 Ambulatory Blocks (14 22 weeks) Community Office: 4 weeks Multi /Immersion: 4 weeks Amb Selective: 4 weeks QI/Immersion: 2 weeks Amb Subspecialty: 2 8 weeks * ½ day per week research option

20 Community Based Teaching Sites Range of settings Rural Suburban West Haven VA Inner city community health centers al faculty appointments / teaching awards Immersion (6 7 half days / week) Night call, hospital and nursing home rounds Exposure to office management and finances Practice opportunities Ambulatory Fridays Supplement to office clinical experience In depth exploration of ambulatory themes Instructional strategies Knowledge: Interactive seminars, peer teaching Skills: Workshops, in service Attitudes: Site visits, debates

21 Ambulatory Friday Themes (2012/13) Psychosocial medicine Geriatrics Health care systems (local and national) Infectious disease Thyroid disease Renal disease/nephrolithiasis Home visits/transitions of care Primary care ophthalmology Primary care dermatology/skin biopsy Addiction Medicine Pulmonary Medicine Overview of the MGH Primary Care Program

22 Massachusetts General Hospital 184 residents Cat(126), MP (15), prelim (16), GPC (6), PC (21) 16 continuity clinic sites PC residents get 1 st choice The MGH Hybrid Model Higher concentration of clinics during ambulatory months (2 3 per week) Lower concentration of clinic during inpatient months Allows greater patient continuity and access ACGME goal of 130 clinics in residency is exceeded

23 MGH Hybrid Model: Ambulatory Structure for All Residents Three 4 week ambulatory blocks, occur in trimesters (12 weeks of ambulatory time) 2 weeks general ambulatory skills (i.e. orthopedics, gynecology, practice immersion, panel management) 2 weeks focused Ambulatory Subspecialty Rotation Longitudinal bi level gen med curriculum Continuity clinics also occur during inpatient rotations 1 st & 2 nd Year Through The Ambulatory Lens 1 st Learning Block 2nd Learning Block 3rd Learning Block Ambulatory Block = 1 month in each learning block Inpatient rotations, elective time, vacation

24 PC v Categorical PC residents rotate together through ambulatory blocks in 1 st & 2 nd year Ambulatory time structured differently, unique experiences for PC residents Extra month of self design ambulatory time in 3 rd year for career exploration Extra 2 week urgent care block for JARs 2 program retreats per year, quarterly program meetings/events, additional mentors Bi level Didactic Curriculum Intern curriculum repeats annually Basic outpatient topics Interactive skills workshops (e.g. diabetes, women s health) Resident curriculum More advanced topics Runs over 2 years Goal no repeat talks

25 Experiential Learning: General Ambulatory Rotation 2 weeks during each ambulatory block 3 4 continuity clinics per week 1 community medicine experience/week Relevant subspecialty clinics (e.g. dermatology, orthopedics, gynecology) Protected time for organizing their practice Opportunity to work on a practice based quality improvement project Community Medicine Experiences Healthcare for the Homeless HIV, TB, and Hepatitis C Care Substance abuse Baycove Methadone Family planning + women s health Planned Parenthood of MA Refugee care Chelsea Health Center Boston Medical Center

26 A Typical Week on Ambulatory Monday Tuesday Wednesday Thursday Friday 7:00-8:00 Ambulatory Intern Report 8:00-9:00 Lecture Lecture Lecture Grand Rounds GIMU Rounds 9:00-12:00 Online Hopkins Modules Dermatology Continuity Lectures/ Workshops Thyroid 12:30-1:30 Noon Noon Noon Noon Noon 1:30-5:00 Continuity Ortho Knee QI Project Continuity Practice Organizing Primary Care Immersion Block See what being a PCP is really like: 4 6 clinic sessions in a week Practice management sessions with nurse and NP Attend practice leadership meetings 1:1 sessions with preceptor Shadowing discussing challenging patients feedback Attend diabetes education and nutrition clinics Practice based improvement project

27 Ambulatory Subspecialty Rotations Focused rotations in a specific subspecialty or population (all outpatient!) e.g. Cardiology, Dermatology, Healthcare for the Homeless Currently 22 options and growing! Primary Care residents additionally do 2 weeks of urgent care clinic to gain proficiency in urgent care approaches and procedures A Typical Week on ASR Monday Tuesday Wednesday Thursday Friday 7:00-8:00 Ambulatory Intern Report 8:00-9:00 Lecture Lecture Lecture Grand Rounds GIMU Rounds 9:00-12:00 UroGyn Colposcopy clinic Women s Mental Health Lectures/ Workshops Fertility 12:30-1:30 Noon Noon Noon Noon Noon 1:30-5:00 Continuity Breast Multi GYN Continuity Pelvic Pain

28 Primary Care Training: Intern Year Immersion Block Global Primary Care curriculum Month long comprehensive curriculum focused on primary care systems at the local and global level 2 Ambulatory Subspecialty Elective Rotations Ambulatory Care Block 12 weeks of ambulatory time Primary Care Training: Junior Year Urgent Care Rotation Leadership Curriculum al Immersion Block Ambulatory Care Block SGIM Annual Meeting 3 Elective ASRs 14 weeks of ambulatory time

29 Primary Care Training: Senior Year Ambulatory Elective Designer Block Focus can be clinical, research, health policy, coursework Primary Care Teaching Senior Rotation Comprehensive curriculum Scheduled teaching sessions (various formats) Observed precepting sessions 2 Ambulatory Subspecialty Elective Rotations 2 Ambulatory Care Blocks 16 weeks of ambulatory time Primary Care Program Retreats Two Annual Retreats Fall and Winter 2013: Focus on Leadership 2012: Procedures in Primary Care 2011: Career pathways in primary care and general internal medicine 2010: Primary Care Health Policy On The Ground: What ians Need to Know

30 Future Directions Pleased with 42 weeks of ambulatory over 3 years could we fit in more? Expanding ambulatory offerings for PC residents Tailored pathways based on career plans Increase # PC residents/class

31 Contact us:

32 Building a Better Mousetrap: Innovations in Primary Care Training APDIM Spring Meeting 2014 Baystate/Tufts Primary Care Residency Program Primary care physicians must be able to manage a wide variety of disease processes, have a thorough knowledge of acute and chronic illnesses and be dedicated to preventative medicine while delivering patient centered, evidence based and quality care. Our goal is to train residents through a careful balance of supervision and autonomy to become leaders in primary care, providing effective, efficient, equitable and patient centered care to adult populations in any setting. Gina Luciano, MD, FACP Sudeep Aulakh, MD Co Director Primary Care Residency Co Director Primary Care Residency gina.luciano@baystatehealth.org sudeep.aulakh@baystatehealth.org Rotation Structure Our program runs concurrently with the categorical residency program; primary care residents will spend significantly more time in outpatient clinic and subspecialty electives. Formative experiences on the hospital wards, critical care units, and emergency department will help residents develop the diverse skills needed to be an accomplished internist. The first 6 months of training is devoted to core rotations that will establish a foundation for longitudinal continuity and subspecialty experiences. The remaining 30 months predominantly consist of alternating 2 week ambulatory and inpatient experiences to maximize continuity and eliminate competing priorities. Sample Schedules BLOCK 1 BLOCK 2 BLOCK 3 BLOCK 4 BLOCK 5 BLOCK 6 BLOCK 7 BLOCK 8 BLOCK 9 BLOCK 10 BLOCK 11 BLOCK 12 YEAR 1 ORIENT ATION WARDS ICU / NF ED/ WARDS/ CCU ED/NF CCU/ WARDS / WARDS / WARDS YEAR 2 WARDS/ WARDS/ QUALITY/ CONSULT WARDS/ / CCU /NF / WARDS /NF / CICU 1

33 Building a Better Mousetrap: Innovations in Primary Care Training APDIM Spring Meeting 2014 YEAR 3 CONSULT/ / WARDS / WARDS ADMIT/ / ADMIT ICU/ ICU/ WARDS/ / CONSULT Ambulatory Rotations Residents spend the majority of time on ambulatory blocks that are composed of a variety of outpatient experiences. These experiences change with post graduate year and individual interests. Home base for our residents is High Street Health Center (HSHC), a Level 3 NCQA Patient Centered Medical Home, which provides care to over 9500 active patients. Care at HSHC is team based with teams consisting of an attending, an advanced practitioner, a nurse, medical assistants and co residents. Sample week on an ambulatory block: AM MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Gastroenterology Community Project Time OFF PM Geriatrics Academic Half Day* Nephrology EVE Continuity at HSHC 2 Endocrine Private Practice Primary Care (Second site) Continuity at HSHC Continuity at HSHC * Academic Half Day occurs on most blocks and is a protected, dedicated educational session for all categorical and primary care residents. Continuity : Residents will be assigned a panel of patients whom they will follow over their three years. Community Project: Residents are expected to become involved in the community to better understand and advocate for their patient population, to develop an appreciation for available patient resources and services and to serve the community in which we practice. The community projects differ vastly from resident to resident. Projects are primarily selected by the resident with oversight from the program directors. Longitudinal Elective Experiences: Residents will participate in up to 5 elective half days per week during ambulatory blocks depending on their year. Core electives are offered in addition to second sites and non traditional electives that can be customized to meet resident

34 Building a Better Mousetrap: Innovations in Primary Care Training APDIM Spring Meeting 2014 interests. Continuity sites are located in highly functional practices in Springfield and surrounding areas, allowing experiences in urban and rural areas as well as socioeconomically diverse communities. Teamwork, Leadership and Teaching Experiences Leadership Training Simulation training for all residents will develop essential clinical leadership skills. Residents are encouraged to participate in the Business in Medicine interest group. 3 rd year residents may be invited to attend the Chief Resident Immersion Training program, a yearly conference dedicated to geriatric and leadership training. 3 rd year residents are encouraged to take an active leadership role in the program. Teamwork and Collaboration Residents will work closely with their primary care teams at HSHC and will become integral team members. Quarterly primary care dinners and journal clubs will foster camaraderie and collegiality among track participants and directors. Primary care dinner attendance is a requirement of the program. Program members will participate in both regional and national SGIM conferences. Teaching Experiences All residents will precept medical students and/or PA students in their final year of training. 3 rd year residents who have mastered core competencies will be given the opportunity to precept junior residents under the supervision of one of the program directors. 3

35 Building a Better Mousetrap: Innovations in Primary Care Training APDIM Spring Meeting 2014 Yale Primary Care Program Schedule Overview PGY1 PGY2 Dates Block A1 clinic # A1 clinic # 6/21 6/30 7/1 7/14 7/15 7/28 7/29 8/11 8/12 8/25 8/26 9/8 9/9 9/22 9/23 10/6 10/7 10/20 10/21 11/3 11/4 11/17 11/18 12/1 12/2 12/15 12/16 12/29 12/30 1/12 1/13 1/26 1/27 2/9 2/10 2/23 2/24 3/9 3/10 3/23 3/24 4/6 4/7 4/20 4/21 5/4 5/5 5/18 5/19 6/4 6/5 6/21 1a CCU 0 Amb-Y 12 1b CCU 0 Vacation 1 2a Neuro 2 Floors 1 2b Pull/Vacation 1 Floors 1 3a Floors 0 Ambulatory 4 3b Floors 0 Ambulatory 4 4a Ambulatory 8 MICU 0 4b Ambulatory 8 MICU 0 5a Floors 1 Pull 1 5b Nights 0 Elective 2 6a Pull/Vacation 1 Floors 0 6b Ambulatory 8 Floors 0 7a Floors 1 Elective 2 7b ED 2 Elective 2 8a MICU 0 Ambulatory 2 8b MICU 0 Ambulatory 2 9a Geriatrics 4 Floors 0 9b Geriatrics 4 Floors 0 10a Floors 1 Ambulatory 8 10b Nights 0 Ambulatory 8 11a Ambulatory 8 Pull/Vacation 2 11b Ambulatory 8 Floors 1 12a Floors 0 Elective 2 12b Floors 0 Pull/Vacation 1 13a Vacation 0 Floors 0 13b Elective 2 Floors 0 4

36 Building a Better Mousetrap: Innovations in Primary Care Training APDIM Spring Meeting 2014 MGH Primary Care Program: 3 Year Overview Intern Year Junior Year Senior Year Immersion Block Urgent Care Rotation Primary Care Designer Rotation Global Primary Care Curriculum Leadership Curriculum Primary Care Teaching Senior Rotation 2 Ambulatory Primary Care in 2 Ambulatory Subspecialty Rotations Ambulatory Care Rotation Items in bold are 4 weeks long Practice Rotation Ambulatory Care Rotation 3 Ambulatory Subspecialty Rotations Subspecialty Rotations 2 Ambulatory Care Rotations 5

37 Building a Better Mousetrap: Innovations in Primary Care Training APDIM Spring Meeting 2014 MGH Primary Care Program: Typical Week on Ambulatory 7:00-8:00 8:00-9:00 9:00-12:00 12:30-1:30 1:30-5:00 Monday Tuesday Wednesday Thursday Friday Ambulatory Intern Report Lecture Lecture Lecture Grand Rounds Online Hopkins Modules Noon Continuity Dermatology Noon Ortho Knee Continuity Noon QI Project 6 Lectures/ Workshops Noon Continuity GMD Rounds Thyroid Noon Practice Organizing

38 Building a Better Mousetrap: Innovations in Primary Care Training APDIM Spring Meeting 2014 MGH Primary Care: Typical Week Women s Health Amb Subspecialty Rotation 7:00-8:00 8:00-9:00 9:00-12:00 12:30-1:30 1:30-5:00 Monday Tuesday Wednesday Thursday Friday Ambulatory Intern Report Lecture Lecture Lecture Grand Rounds Urogyn Noon Continuity Colposcopy clinic Noon Breast Multi Women s Mental Health Noon GYN 7 Lectures/ Workshops Noon Continuity GMD Rounds Fertility Noon Pelvic Pain