A RESIDENT’S INTERNAL MEDICINE

PRACTICE The decision-making experience of restdents in a primary care internal medicine training practic e was examined. The patient population provided residents appropriate training opportunities but the experience of many residents making decisions about

prevalent primary care problems was often inadequate. The residents’ evaluation of their educational experience with patients suggests that several elements of patient care affect their ability to learn. These include the occurrence of diseases in their patients, opportunities to treat and follow patients, the chance to use diagnostic procedures, and the option of reviewing their care with supervisors and consultants or through reading. The results of this study and the current understanding of the development of clinical judgment are discussed as argumentsfor evaluating internal medicine training programs in part by examining the content of residents’ decisionmaking opportunities in their ambulatory

patient practices.

THOMAS J. McGLYNN, Jr. The Milton S. Hershey Medical Center The Pennsylvania State University,

Hershev

ROBERT F. MUNZENRIDER The Pennsylvania State University, Middletown

JOHN ZIZZO Valley Health Systems, Inc. Huntington, West Virginia

AUTHORS’ NOTE: This article was presented in part to the American Federation of Clinical Research, Health Care Research Section, January 27, 1978, Boston, Massachusetts. We are indebted to the residents who willingly committed their time and perspectives to this research project.

463

464

Evaluation and the Health Professions

/ December 1979

development of effective primary care internal medtraining programs confronts academicians as a issue in medical education (Proceedings of a Conference on major the Role and Training of the General Internist, 1977; Pellegrino, 1976). Although the American Board of Internal Medicine (1977) has defined the physicians to be produced by training programs, the content of training experiences varies among programs and continues to be a subject for debate. Since 1974, the internal medicine faculty of The Milton S. Hershey Medical Center of The Pennsylvania State University has been examining the content of its residents’ ambulatory patient practices. It has attempted to evaluate whether the residents are in fact being provided adequate and relevant ambulatory practice experience in preparation for primary care careers. These evaluations have identified potential weaknesses of primary care-oriented training experiences and have provided insights into how residents learn in the ambulatory care environ-

he icine

This article reports some of these observations and offers suggestions regarding how primary care internal medicine outpatient programs should be evaluated and how research concerning the development of primary care internal medicine programs can be extended. ment.

SETTING AND BACKGROUND

Four academic full-time internists staff The Milton S. Hershey Medical Center internal medicine practice. The center is located in rural central Pennsylvania and the practice serves as a training model for both medical residents and students. The study reported here examines only one component of the internal medicine training program, the ambulatory patient practices of 22 second- and third-year residents participating in the program between 1974 and 1976. Beginning in the last two months of their first year of residency, residents committed one-half day each week to their internal medicine practice throughout their training career. They were the

primary physicians responsible

for

providing ongoing

contact

McGlynn

et

al.

/ A RESIDENT’S PRACTICE

465

with patients who were discharged from the hospital, referred for consultations by physicians, or were self-referred ambulatory patients. Secondary care services accounted for almost half of the practice utilization by unusually socioeconomically stable patients from diverse backgrounds throughout central Penn-

sylvania.

MATERIALS AND METHODS

In May of 1975 and 1976 over 98% of the charts of all patients in the residents’ practice were reviewed by the residents and their faculty supervisor. The review focused on resident decisionmaking opportunities. The residents completed a questionnaire about their educational experience, recorded patient background characteristics, and filled out problem lists and activity logs for each of their patients. They recorded the frequency with which they made clinical decisions about all of their patients’ chronic and temporary problems and the drugs they initiated, adjusted, or maintained for each patient. The activity logs of each patient were reviewed, compared to the chart notes, and corrected by the

faculty practice director. For each occasion

on

which

a

resident addressed any aspect of

particular problem, he received one credit for making decisions about that problem. On some occasions residents were given credit for making decisions about drugs they used to maintain patients’ chronic problems, although they were not given credit for treating these problems on some patient visits. This distinction was necessary so that the data reflected as accurately as possible the specific issues on which residents’ decisions a

focused. The resident problem-solving and drug use experience data presented in this study represents the experiences of 10 residents with 590 patients who were seen on 1,568 visits during 1974-1975. The resident evaluations of how they learn through their practice activities and the ratings of their experiences are drawn from a review of the practices of 12 residents who treated 637 patients in 1975-1976. The problem-solving and drug experience data from

466

Evaluation and the Health Professions

/ December 1979

1974-1975 are presented because they are the most thoroughly reviewed data which have been collected. However, resident evaluations of the learning experiences were unevenly collected during that year. For this reason, evaluation data for the following year are presented. The practice setting and activities remained essentially unchanged during this two-year period and through 1977. The presentation of the more complete evaluation data from 1974-1975 and 1975-1976 continues to be both appropriate and desirable.

RESULTS

The first objective of the evaluation was to determine whether a rural population, which utilized the internal medicine practice for a variety of purposes, provided adequate clinical material to prepare residents for careers in general internal medicine. Table I lists the 35 most frequent problems 10 residents encountered in their practice during 1974-1975. Problems listed in Table I are very similar to those encountered in internal medicine practices as identified by Burnum and others (Burnum, 1973; National Disease and Therapeutic Index, 1973-1974). These 35 problems accounted for 74% of the residents’ decision-making experiences, while the 10 most prevalent problems accounted for half of the

decision-making experience. A similar analysis of prescribing habits showed that the drugs used by the residents were those frequently employed by internists and reflected the service needs of the patient population. Only 24 drugs were commonly prescribed or maintained, on a minimum of 12 or more occasions, during the study year. When the residents used the commonly administered medications, they prescribed diuretics or antihypertensive agents on 37% of these occasions. Potassium supplements and digitalis preparations 10% of these occasions. Both sedatives and psychotropic agents were dispensed on 9% of the occasions. One or more drugs were prescribed to 58% of the patient population.

were

each used

on

The number of visits by individual patients provided a measure of residents’ continuity of care experiences. The number of prob-

McGlynn

et al.

/

A RESIDENTS PRACTICE

467

TABLE 1

Frequency of Common Patient Problems in the Internal Medicine Residents’ Practice at The Milton S. Hershey Medical Center

lems residents evaluated for each

patient provided a measure of their opportunity to practice interface medicine. Only 35% of the patients used the practice more than the minimum one or two visits. Of the patients, 64% presented more than one problem and 30%, four or more problems. An average resident had contact with 59 patients during the year and followed an average of 20 patients who provided him continuity of care experience by visiting the practice on four or more visits. Each resident also evaluated an average of 39 patients each year who presented more than one problem and provided some experience with interface medicine.

468

Evaluation and the Health Professions

/

December 1979

The data about patient problems, continuing care opportunities, and resident prescribing habits indicate that the practice provided the residents ample opportunities for training in primary care internal medicine. However, individual training experiences varied widely and individual deficiencies are readily apparent. To illustrate, the resident with the most patients (105) and patient visits (273) acquired a broad experience treating a large number of common and uncommon problems over the year. More important, he acquired a reasonably in-depth experience with 29 common internal medicine problems. In contrast, the resident with the fewest patients and the least visits (36 patients and 127 visits) received a more restricted exposure to common internal medicine problems and acquired an in-depth experience with only 6 problems. Table 2 displays an analysis of the variation of exposure and experience among residents with the 12 most prevalent patient problems. For this analysis we assumed that a resident who addressed a problem on six or more occasions in one or more patients would be likely to develop his managerial skills for that problem through a relatively in-depth experience. (The block numbers refer to the number of occasions each resident dealt with

problem.) This arbitrary standard should undoubtedly vary according to the nature of the patients’ problems and other factors. However, it provides a useful perspective with which to evaluate individual resident’s activities. In Table 2 the problems for which each resident did not fulfill these minimum experience criteria are shaded. These shaded areas show that the experiences of many residents with common primary care problems over one year were inadequate in many instances. Individual resident’s experiences using four index drugs also varied dramatically. Table 3 displays the experiences of the 10 residents using four index drugs frequently prescribed by internists : insulin, digitoxin, xanthine bronchodilators, and prednisone. The experience of many residents with each of these drugs was limited or nonexistent. The prescribing experience of residents reflected both an unevenness of patient distribution and an unevenness of continuing care commitment among the residents. each

In many instances residents did not continue the physicianpatient relationship long enough to appreciate the therapeutic

McGlynn

et

al. / A RESIDENT’S PRACTICE

469

TABLL22

Analysis of the Variation in Experience Among Ten

Residents

with Twelve Patient Problems

of the medications they prescribed or to encounter side effects and make dose adjustments. The answers of the 12 residents who reviewed 637 physicianpatient relationships in 1975-1976 provide a first step toward understanding the elements of the residents’ practice which foster development of their clinical skills in an ambulatory patient environment. First, the residents provided an overall evaluation

efficacy

470

Evaluation and the Health Professions

/ December

1979

TABLE3

Resident Experience with Four Commonly Used Drugs in their Internal Medicine Practices at The Milton S. Hershey Medical Center

of their educational experience by rating their relationship with each of their patients. Each relationship was rated in one of four categories: excellent (highly instructive), good (learned a little), fair (service of value to the patient: educational yields small), or poor (service of limited value to the patient: no instructional value in the case experience). In all, ratings were obtained for 98% (627) of the cases in residents’ practices that year. They rated 28% (174) of their case experiences as excellent, 31 % (195) as as fair, 14% (88) as poor. between the residents’ ratings of their experiences and their use of training resources during contacts with individual patients were then examined. Their answers indicated that the opportunity to follow patients was a factor which influenced their ratings of patient care experiences. Only 21 % of the residents’ experiences with patients who visited the practice on one, two, or three occasions were rated excellent, while 45% of the relationships with patients who visited the practice on seven or more visits received an excellent educational rating (p < .05). This relationship suggests that more valuable educational experiences are provided when contact with patients is extended over a period of time and over several visits.

good, 27% (170) Relationships

McGlynn

et

al / A RESIDENTS PRACTICE

471

The residents used the services of consultants in more than onethird (194) of their cases and requested input from faculty supervisors in almost half (274) of their cases. Consultants provided educationally valuable feedback to the residents in 79% of the cases in which they participated. Faculty supervisors provided productive feedback in 67% of the cases in which they participated. Figure 1 shows a relationship between the residents’ ratings of their professional experiences with patients and their use of consultants and supervisors and their following the patients over time. During contact with patients which were rated highly, the residents frequently learned by using consultants and supervisors and by following the patients. During poorly rated patient contacts, residents usually did not follow the patients or use consultants and supervisors. Moreover, Figure I shows that not only were patients followed and consultants and supervisors used more often in higher rated cases but also that the educational yield from using these resources was highest during contacts with patients which were given overall high educational value ratings. (The striped areas indicate the percentage of cases in each patient group in which the resource was used. The darkened areas indicate the percentage of cases in which use of the resources resulted in the resident acquiring educational insights. N = 566,

p