Objective: Market and technology innovations have greatly changed the teaching and practice of medicine in the past 10 years. This report describes an innovation in the ambulatory education of internal medicine residents: a subspecialty continuity clinic. Methods: A subspecialty continuity clinic was developed to improve the training of internal medicine residents in caring for complex ambulatory patients. The clinic structure is discussed from the perspective of patients, residents, and subspecialists. Logistical challenges and solutions are described. Results: Two and one-half years into the program, feedback from residents and subspecialists has been positive. In-training examination scores are relatively higher in the involved specialties, and residents are managing illnesses they rarely saw in an outpatient setting before this program. Conclusion: This experience suggests that a subspecialty continuity clinic is worthwhile and practical in educating primary care residents.

Introduction

ne dilemma facing internal medicine residency program directors is how to provide education in both general and subspecialty internal medicine. Leaders in medical education have been calling for more unity of subspecialty and primary care internal medicine. '2 A survey of Associates of the American College of Physicians in 1997 suggested that young internists are concerned that the distinction between family medicine and internal medicine is becoming blurred and also that more training in subspecialty medicine might make general internal medicine a more attractive career choice.3

Simultaneously, contemporary medical care and education have shifted to the outpatient arena.4 A recent survey by Swing and Vasilias showed that most teaching of continuity care occurs in general internal medicine practices associated with tertiary medical centers.5 Residents on elective rotations in subspecialty clinics are usually exposed to only a "snapshot" of an individual patient's condition. This may not allow observation of disease progression or therapeutic responses in diseases classically managed by subspecialists. Is there a way for training programs to provide education in the continuity care for patients managed by subspecialists? In some settings, especially in the military, general internists are responsible for integrating and providing care previously provided by their subspecialty colleagues.

To improve our residents' experiences with patients traditionally followed by subspecialists, we developed a program designed to focus on continuity care from the perspective of a subspecialist. This Resident Subspecialty Continuity Clinic (RSCC) is described below.

Methods

Study Site

Madigan Army Medical Center is a community-based teaching hospital and tertiary care referral center that manages more than 1 million outpatient visits annually. Nine internal medicine residents graduate each year, and our medical center supports several other residencies. In addition to inpatient rotations, our residents rotate for 1-month outpatient rotations in each of the disciplines of internal medicine. Residents also serve for onehalf day per week in a continuity primary care clinic (about 44 weeks per year). Residents are responsible for the primary care of 60 to 90 patients, depending on their level of training. Our residents follow some patients in the primary care clinic who see subspecialists within our department for acute and chronic diseases. For example, a resident might provide primary care for a patient with rheumatoid arthritis while a rheumatologist administers and monitors the cytotoxic drugs. Similar situations occur for patients with human immunodeficiency virus (HIS, cancer, degenerative neurologic diseases, and chronic renal failure.

At our department retreat 3 years ago, the RSCC was proposed as a way for residents to participate in the longitudinal care of patients from a subspecialist perspective. As its name suggests, the RSCC provides an opportunity for residents to follow patients with direct subspecialist supervision for an extended time. The sections below describe the clinic design and observations we have made in the 2.5 years since the clinic's inception.

Clinic Design

Patient Perspective

The RSCC clinic enrolls patients through three different pathways. Patients can be referred from a resident's own primary care panel, followed up from a ward or subspecialty rotation, or be assigned to interested residents by the subspecialty clinic.

In the first pathway, residents use the RSCC to obtain subspecialist consultation for their own primary care patients. For example, a patient in a resident's panel who develops Grave's disease may initially see her primary physician (the resident) in our primary care clinic. She may then follow up with the same resident and an endocrinologist in the RSCC endocrinology clinic. The resident participates in the entire diagnostic and therapeutic process with the patient and has the expertise of a subspecialist physician preceptor. Another patient with endstage renal disease and severe congestive heart failure could meet with the resident in the nephrology clinic one week and in the cardiology clinic another week. This provides subspecialty care for the patient while maintaining unique continuity for the patient and teaching for the resident.

Second, patients can enroll in the RSCC for follow-up after an encounter on a subspecialty or ward rotation. A patient seen during the last week of a pulmonary rotation can follow up to discuss test results with the resident and pulmonologist after the resident ends the typical 1-month rotation. Patients evaluated in the emergency room or admitted by the resident can also be followed through the appropriate subspecialty clinic in the RSCC.

In the third pathway, we may assign residents a limited number of subspecialty patients. Our subspecialists select patients with appropriate diseases for the clinic and refer them to the RSCC coordinator. The resident can then assume the continuing role of subspecialty consultant without necessarily assuming the patient's primary care.

Resident Perspective

The RSCC format was proposed and developed with input from residents. The RSCC is not found in one location but could be defined as "what medicine residents do on Monday afternoons." Residents participate on Monday afternoons except during intensive care unit rotations, rotations at outside hospitals, and when on call or post call. Each resident has three 1-hour slots available. On a given day, a resident might see one patient in the hematology clinic at 1 p.m., another patient in the nephrology clinic at 2 p.m., and a third patient in the infectious diseases clinic at 3 p.m. One-hour appointments are usually enough time to see a patient, provide the patient with appropriate teaching, and get to the next clinic. Residents are reminded which clinic to go to each week through an e-mail message sent out on the preceding Thursday.

Subspect/ist Perspective

Currently, appointments are booked in nephrology, endocrinology, infectious diseases, cardiology, neurology, pulmonary, hematology/oncology, gastroenterology, rheumatology, dermatology, gynecology, and psychiatry clinics. Each clinic has three 1-hour slots available, which are often filled by three different residents. The e-mail message sent to residents by our administrative assistant also goes to each clinic, so that clerks and staff physicians know which patients to expect. Some of the subspecialists see their own patients in the afternoon as well, scheduling them between the RSCC patients. Some of the subspecialists spend the afternoon on administrative duties in addition to supervising the care of the three scheduled RSCC patients. Each subspecialty clinic has developed its own policy to balance productivity for the clinic and teaching for the residents.

Scheduling

Arranging the appointments was initially difficult. After a year of decentralization, we began scheduling patients through a dedicated administrative assistant. This assistant takes phone calls from residents or patients and keeps simultaneous clinic and resident schedules. This system is separate from our usual scheduling, but it works well and takes less then 5 hours per week of administrative time. When a resident assigned to a given patient is unavailable, the patient is given the option of seeing another resident designated as a surrogate or seeing the subspecialist directly.

Results

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