APM perspectives

Ambulatory Training Since Duty Hour Regulations: A Survey of Program Directors

Materials and Methods

We drafted questions to address the targeted topics and then asked faculty knowledgeable about local residency programs to comment on how feasible it was to answer them. We forwarded revised questions to the Association of Program Directors in Internal Medicine Survey Committee, which provided additional feedback. The committee incorporated these questions into its yearly web-based internal medicine residency program director survey, administered by the Mayo Clinic Survey Research Center. In

Results

The mean total percent of time residents spend in the ambulatory setting is 46.9% (standard deviation, 25.5%). This proportion increases over the course of residency, from 35.7% for first-year residents (postgraduate year 1), to 49.0% for second-year residents (postgraduate year 2), to 55.9% for third-year residents (postgraduate year 3). Although all residents have a personal continuity clinic as required by Accreditation Council for Graduate Medical Education standards, the majority of

Discussion

We believe that this survey of a national sample of residency program directors is the first description of how ambulatory practice knowledge and skills are taught to internal medicine residents across the range of residency programs. This realization is surprising because there have been many calls for improvements to ambulatory training and many descriptions of innovative approaches.

Most program directors do not have difficulty meeting the 33% required clinical time in ambulatory practice;

Limitations

Although we believe our survey is the most complete description of ambulatory training in internal medicine that is currently available, it does have limitations. First, many programs did not respond, and we were not able to determine whether the programs that responded are representative. Programs that are proud of recent innovations or have concerns about the impact of duty hour regulations might have been more likely to respond. Furthermore, weaker programs with less dedicated time for

Conclusions

Regardless, this survey should provide individuals interested in internal medicine ambulatory training with a sense of how it is typically done today, as well as a sense of which innovations are being adopted. In today's academic environment, programs face many challenges; however, the importance of ambulatory education cannot be forgotten. Our findings that duty hour regulations might have forced changes that limit the quantity of continuity clinic experience should be of concern to those who

Acknowledgments

We gratefully acknowledge the efforts of the Mayo Clinic Survey Research Center for assistance with survey design and data collection. We also thank Eric S. Holmboe, MD, and Lisa M. Bellini, MD, for helpful comments and advice regarding early drafts of the questionnaire.