title: Influence of ambulatory care rotations on gatekeeping referral patterns of categorical medical residents.
abstract: OBJECTIVE
  To determine whether a required ambulatory care block rotation for categorical medicine residents improved their ambulatory care skills and altered their outpatient gatekeeping referral patterns.
  
  
  METHODS
  In 1991-92 a prospective cohort study was conducted of 39 categorical medicine residents at the University of California, San Francisco, and their continuity clinic patients. Before and after the residents participated in an ambulatory care block rotation, the residents were surveyed about their ambulatory care skills, and the frequencies and indications for referral of their continuity clinic patients were obtained. Statistical methods consisted of Student's t-test, the Wilcoxon rank-sum test, and Mantel-Haenszel analysis.
  
  
  RESULTS
  The 39 residents reported significant improvement in ambulatory care skills. Yet the proportions of the residents' 4,276 patients referred before and after the intervention were 14.2% and 12.4%, respectively (adjusted odds ratio 1.02, p > .9). One-fourth of the referrals were for procedures both before and after the intervention (adjusted odds ratio 1.06, p > .5).
  
  
  CONCLUSIONS
  Despite improvements in the ambulatory care skills of the categorical medicine residents, the residents' gatekeeping referral patterns remained unchanged. Ambulatory care curriculum changes need to be evaluated from the perspective of the trainee and from the perspective of whether these changes influence patient care.
authors.affiliation: Department of Medicine, University of California, School of Medicine, San Francisco.
authors.forename: M A
authors.initials: MA
authors.lastname: Papadakis
authors.forename: M
authors.initials: M
authors.lastname: Kagawa
mesh_terms: D000553:Ambulatory Care / Q000458:organization & administration*; D002983:Clinical Competence; D015331:Cohort Studies; D006787:Hospitals, Veterans; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration*; D008511:Medicine; D010044:Outpatient Clinics, Hospital; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012495:San Francisco; D013038:Specialization