title: Moving forward in GME reform: a 4 + 1 model of resident ambulatory training.
abstract: BACKGROUND
  Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.
  
  
  OBJECTIVE
  To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.
  
  
  METHODS
  A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.
  
  
  METHODS
  Residents, faculty, and administrative staff.
  
  
  METHODS
  Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.
  
  
  RESULTS
  A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents' learning opportunities increased (p = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (p < 0.0001). Satisfaction with ambulatory training improved (p < 0.0001). Self-reported empanelment also increased (p < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (p < 0.0001).
  
  
  CONCLUSIONS
  A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.
authors.affiliation: Division of Hospital Medicine, North Shore LIJ Health System, Great Neck, NY, USA. schaudhr@nshs.edu
authors.forename: Saima I
authors.initials: SI
authors.lastname: Chaudhry
authors.forename: Sandy
authors.initials: S
authors.lastname: Balwan
authors.forename: Karen A
authors.initials: KA
authors.lastname: Friedman
authors.forename: Suzanne
authors.initials: S
authors.lastname: Sunday
authors.forename: Basit
authors.initials: B
authors.lastname: Chaudhry
authors.forename: Deborah
authors.initials: D
authors.lastname: Dimisa
authors.forename: Alice
authors.initials: A
authors.lastname: Fornari
mesh_terms: D000553:Ambulatory Care / Q000379:methods / Q000639:trends*; D000554:Ambulatory Care Facilities / Q000639:trends; D003625:Data Collection / Q000379:methods; D004503:Education, Medical, Graduate / Q000379:methods / Q000639:trends*; D006801:Humans; D007388:Internal Medicine / Q000379:methods / Q000639:trends; D007396:Internship and Residency / Q000379:methods / Q000639:trends*; D018802:Patient-Centered Care / Q000379:methods / Q000639:trends; D011331:Private Practice / Q000639:trends; D015397:Program Evaluation / Q000379:methods / Q000639:trends*