The paradoxical influence of resident continuity clinic on primary care.

Enhancing access to primary care is the focus of much national debate. With health care reform imminent, our country is facing a shortage of physicians, particularly primary care physicians to serve a growing population of individuals with health care coverage. As an internal medicine (IM) residency program director, I find myself wondering if the traditional continuity clinic experience draws residents toward, or away from, a career in primary care. If we are to meet society's needs, we must consider better ways to engage our future physicians in primary care. Medical schools are exploring ways to use their recent enrollment expansion for the public good.1 Interventions being considered to increase the number of medical students with an interest in primary care include changing admission qualifications, reforming the curriculum, and expanding clinical sites to community settings, rural sites, and students' home communities.2 These approaches are important, but the effort cannot be limited to interventions at the undergraduate medical education level. We must be mindful of the factors and experiences that influence residents' career choices. The conflict many residents experience between required inpatient and outpatient duties, specifically the timing of continuity clinic, may paradoxically be driving residents away from a career in primary care. Traditional IM residency continuity clinic is one-half day sessions weekly throughout training. The Accreditation Council for Graduate Medical Education requirements for continuity clinic are complex.3 Requirements include scheduling that minimizes conflicts between inpatient and ambulatory experiences, yet this requires residents to manage their continuity patients interspersed between other ambulatory patient visits. In addition to acquiring the knowledge and skills for ambulatory care, developing longitudinal relationships with patients, and learning unique systems-based processes, residents must receive evaluation of their performance data for their chronic disease management and preventive care, and develop a data-based action plan. All of this must occur in at least 130 sessions, over 30 months of training, and it may not be interrupted by more than one month, with residents expected to concurrently participate in inpatient, intensive care, and other clinical rotations. This makes it challenging to ensure compliance, especially given the limits on resident duty hours.4 As a primary care physician who supervises residents on inpatient wards, I empathize with my residents' struggles to balance inpatient and ambulatory care responsibilities. When I am assigned inpatient duties, I find it challenging to devote adequate time to my clinic. Although I am passionate about primary care and have a strong administrative support system, clinic can feel burdensome during these busy times. If we wish to engage residents in primary care, we must restructure the traditional model. This should do more than minimize inpatient and outpatient duties; we must separate them. Innovative programs have developed schedules that successfully do this, alternating “blocks” of inpatient time with clinic time, with weekly intervals (4∶1 or other ratios) or 6 to 12 consecutive months of clinic.5 At our institution, we are planning to alternate clinics every other month with a practice partnership model, such that patients are assigned to a resident pair. Creating schedules that accommodate unique institutional structures deserves strong consideration. By restructuring traditional continuity clinic to decrease the tension from inpatient and outpatient duties, we may find residents enjoy spending time in clinic and are receptive to the rewards of a career in primary care.