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Medical Education  |   December 2016
Alternative Scheduling Models: Improving Continuity of Care, Medical Outcomes, and Graduate Medical Education in Resident Ambulatory Training
Author Notes
  • Disclaimer: The opinions and assertions contained herein are the private views of the author and do not reflect the views of the US Department of Veterans Affairs, where he is currently affiliated. 
  •  * Address correspondence to Ali J. Hussain, PhD, DO, 2361 S State St, L15, Chicago, IL 60616-2009. E-mail: drajhussain@gmail.com
     
Article Information
Medical Education / Graduate Medical Education
Medical Education   |   December 2016
Alternative Scheduling Models: Improving Continuity of Care, Medical Outcomes, and Graduate Medical Education in Resident Ambulatory Training
The Journal of the American Osteopathic Association, December 2016, Vol. 116, 794-800. doi:10.7556/jaoa.2016.155
The Journal of the American Osteopathic Association, December 2016, Vol. 116, 794-800. doi:10.7556/jaoa.2016.155
Abstract

An association has been consistently made about continuity of care with improved quality of care and improved medical outcomes. However, resident ambulatory block scheduling prevents the optimization of continuity of care in ambulatory clinical education. The author performed a PubMed search for studies examining continuity of care and curriculum scheduling in US primary care residency clinics. These studies indicate the success of an X + Y scheduling model in resident ambulatory training. Additional benefits have also been noted, including improved clinical teaching and learning, increased sense of teamwork, increased resident satisfaction, improved recruitment and retention, improved patient satisfaction, and elimination of year-end patient care issues after graduation. Many allopathic institutions have begun to implement such curricular changes with demonstrated success. The author argues that osteopathic graduate medical education should embrace the X + Y scheduling model.

A collaboration between the JAOA and the American Association of Colleges of Osteopathic Medicine (AACOM) to recruit, peer review, publish, and distribute research and other scholarly articles related to osteopathic medical education.

Keywords: clinic scheduling models, continuity of care, graduate medical education, residency

Continuity of care is consistently associated with improvements in quality of care and outcomes in medical practice and graduate medical education (GME).1-4 Numerous studies have examined how modifying primary care residency clinic schedules can improve continuity of care and medical education in ambulatory clinics.4-9 Accordingly, some postgraduate programs have restructured their GME curriculum to separate inpatient and outpatient clinical responsibilities.10-18 This novel curricular scheduling method is often referred to as the “X + Y” model, where X refers to the inpatient rotations and Y refers to designated ambulatory blocks.17 In this model, blocks of traditional inpatient rotations are alternated with dedicated ambulatory blocks.17 X + Y models have successfully improved patient care and GME.11-14 Its increasing popularity is evidenced by the rising number of Accreditation Council for Graduate Medical Education (ACGME) programs adopting this new method each year.19 In this article, I examine the literature for alternative clinic scheduling models aimed at improving continuity of care through resident ambulatory training. 
Methods
A Google search using the term plus block scheduling residency clinic was conducted to find residency programs that currently institute X + Y schedules in their curricula. A literature search was also performed using the MEDLINE database via PubMed for variations of the following terms: continuity of patient care, continuity of care, internship and residency, clinics ambulatory care facilities, and appointments and schedules. Sources cited in the resulting articles were also obtained and included in the analysis when appropriate (Figure). 
Figure.
Flow chart of literature review process for studies with alternative residency clinic scheduling models.
Figure.
Flow chart of literature review process for studies with alternative residency clinic scheduling models.
Exclusion criteria were unavailable free full-text articles, duplicate articles, foreign studies conducted outside of the US health care system, articles published before 2005, or articles that had irrelevant results, such as those focusing on attending physicians or directors. Articles that did not involve residency clinics, were not scheduling-related, or were focused on medical specialties other than primary care (defined as family practice, internal medicine, and pediatrics) were also excluded. All remaining articles were included. 
The collected findings were examined and categorized according to their relevance to 1 of 3 categories: continuity of care in primary care residency clinics, curricular barriers to continuity of care, and recent innovative approaches to dealing with such barriers. Findings were synthesized into a chronological narrative of developments over the past decade, focusing on the current rise in the use of alternative residency clinic scheduling models. 
Results
The Google search revealed that the following institutions have implemented the X + Y scheduling model: Tulane University, Temple University, Baylor University, University of Chicago, University of Vermont, and Osceola Regional Medical Center in Kissimmee, Florida. The literature review resulted in 161 resulting abstracts, 152 of which were excluded. By manually cross-referencing and examining works cited in the remaining 9 articles, 27 additional articles were identified and included in the analysis (N=36). 
Continuity in Primary Care
Systematic reviews have validated the notion of an association between continuity of care and improved quality of care and patient outcomes.1,2 Studies focusing on GME have noted correlations between continuity of care by residents and improved outcomes in patients with chronic conditions such as diabetes and hypertension.3,4 Perhaps owing to this increasing body of evidence, both the ACGME and osteopathic GME insist on continuity of care in resident ambulatory training.10,20 Guidelines from the ACGME require “a longitudinal continuity experience in which residents develop a continuous, long-term therapeutic relationship” with their patients.10 Similarly, the American Osteopathic Association’s Basic Standards for Residency Training in Internal Medicine mentions that “the resident must develop a continuity panel of patients in the ambulatory clinic.”20 
Studies examining different methods of altering clinic schedules to improve continuity of care in residency clinics have yielded varying results. For example, 4 studies4-7 found that these methods resulted in increased continuity of care. Neher et al5 found that increasing clinic frequency improved continuity of care, and Hern et al6 concluded that patient care management teams improved continuity of care, office efficiency, and patient satisfaction. A third study showed that assigning fixed day schedules for residents resulted in better continuity of care than weekly variability.7 Warm et al4 implemented an ACGME educational innovations project that introduced a major structural change in the traditional curriculum: an ambulatory “long block” that resulted in improved continuity of care and outcome measures. By contrast, some methods examined in other studies resulted in decreased continuity of care. One such study evaluated an attempt to redesign the residency curriculum to a 50/50 outpatient-inpatient model,8 and another revealed decreased continuity with open-access scheduling despite increased availability for walk-in and same-day appointments.9 However, these methods are all limited by the structural barriers inherent to resident ambulatory training. 
Structural Curricular Barriers to Continuity in GME
A major barrier to achieving patient-physician continuity in an outpatient residency clinic lies in the very nature of clinical GME. Whereas primary care physicians generally care for their own patients, continuity of care is particularly difficult to achieve in a resident ambulatory training program faced with the complexity of coordinating patient visits with the schedules of multiple interns, residents, and preceptors. Without structural checks in place, a patient might be seen by any resident available in clinic on a particular day, which causes some physicians to question the term resident continuity clinic.21 Such scheduling difficulties are often complicated even further because most residents have simultaneous inpatient and outpatient curricular responsibilities. 
In 2006, the American College of Physicians and the Association of Program Directors in Internal Medicine published their concerns that the US residency education system needed to be redesigned, including improved ambulatory education.22,23 In 2007, the Alliance for Academic Internal Medicine Education Redesign Task Force recommended improving outpatient clinical training “by providing patient-centered longitudinal care that addresses the conflict between inpatient and outpatient responsibilities.”24 By 2014, the Educational Innovations Project Ambulatory Collaborative examined a number of studies showing that such “conflicting responsibilities across care settings are a barrier to an optimal outpatient experience.”25 Moreover, residents are aware of the effects of clinic scheduling on continuity,20 and correlations have been noted between residents’ perceptions of outpatient clinical training experiences and their long-term career choices,27-30 with potentially drastic effects on the future of primary care medicine in the United States. 
In 2009, ACGME guidelines began to require programs to develop “schedules for ambulatory training that minimize conflicting inpatient and outpatient responsibilities.”10 The American Osteopathic Association does not appear to have any similar requirements for osteopathic residency programs to prevent these scheduling conflicts.20 
Innovative Approaches: X + Y Scheduling Model
The most promising recent development seems to be the increasingly popular X + Y scheduling model. This model blends the most successful aspects of the 4 aforementioned studies4-7 (ie, increased clinic frequency, the formation of patient care teams, establishing fixed schedules, and a contiguous block of clinic time) with the added benefit of eliminating conflicting inpatient and outpatient responsibilities throughout the entire length of residency training. 
Mariotti et al11 introduced this X + Y scheduling system in 2010. The authors eliminated the traditional residency schedule of weekly outpatient clinic time while simultaneously on a curricular rotation. Instead, between each 4-week curricular rotation block, an entire week in outpatient clinic was scheduled (ie, a 4+1 block schedule), effectively eliminating conflicts between rotation responsibilities and outpatient clinic responsibilities. Mariotti et al11 found that this schedule led to a more conducive learning environment, a greater ability for residents to focus on their patients, an increased sense of teamwork, the ability to schedule same-week follow-up appointments, the ability to see their patients any day of the week, a greater efficiency in preceptor teaching and in resident learning, and an increase in resident ownership of their patients’ care. The method was also found to promote continuity and access to care for patients.11 
In 2012, Hoskote et al12 published their success with a 6+2 schedule, noting that a 2-week clinic block afforded the additional benefit of dedicated time for numerous educational opportunities, such as regularly planned ambulatory care workshops. That same year, the Greater New York Hospital Association13 published a toolkit comprising 3 successfully implemented X + Y schedules: the 4+1 model at Lehigh Valley Health Network in Allentown, Pennsylvania;11 the 4+1 model at Northwell Health in Great Neck, New York;14 and the 6+2 model at St. Luke’s Hospital Center in New York.12 In 2013, the Northwell Health system that was referenced in this toolkit published the results of their 4+1 model, citing enhanced learning, reduced fragmentation of care, and improved satisfaction.14 
The practical successes of this once theoretical model were becoming noticeable, and medical educators began to observe that successful findings were “consistent across various sites, including private practice offices, a hospital based clinic, and a non–hospital-based, patient-centered home setting.”15 In 2013, Shalaby et al16 published a brief summary of how a program of any size and scope can customize the concept to individual program specifications. Another article by Shalaby et al17 was published in 2014 and reported that dozens of programs had implemented variations of the model since the publication of the “novel template” article. Other studies18,31 on X + Y scheduling models found this model to be beneficial. Additional research in this area is likely forthcoming. 
Discussion
Opportunities
Numerous advantages of X + Y scheduling models have been noted, including increased continuity of care, improvements in clinical teaching and learning, and increased sense of teamwork. In addition to resident satisfaction (and subsequent recruitment and retention in primary care), improved patient satisfaction has also been documented (Table).32 
Table.
Comparative Summary of Traditional Residency Clinic Scheduling vs X + Y Scheduling23
Element of Residency Clinic Traditional Scheduling X + Y Scheduling
  Responsibilities Conflicts between simultaneous inpatient and outpatient responsibilities No ambulatory training responsibilities while on rotation and no rotation responsibilities during clinic week
  Team No functional team structure Each incoming intern assigned to a practice team from day 1
  Schedule Difficult to maintain patient continuity Schedules staggered so at least 1 member of each team is available in clinic at all times
  Coverage No clear mechanism for cross-coverage Practice teams divided into subcohorts so at least 1 team member is available in clinic at all times
  Resident patient hand-off No clear mechanism for transition Unnecessary; all members of patient's care team aware of patient's ongoing care plan
  Resident year-end hand-off No clear mechanism for transition Unnecessary because remainder of care team remains in place
  Clinic experience Disjointed for residents(eg, Mondays only, afternoons only) Seamless Monday through Friday clinic experience, morning through evening (with same true for rotation)
  Educational experience Disjointed for residents and preceptors Seamless with all members present from the beginning to the end of the day
  Duty hours No change No change
  Call scheduling No change No change, but free weekends during clinic weeks may increase opportunities for “golden weekends” (ie, no call or rotation duties)
Table.
Comparative Summary of Traditional Residency Clinic Scheduling vs X + Y Scheduling23
Element of Residency Clinic Traditional Scheduling X + Y Scheduling
  Responsibilities Conflicts between simultaneous inpatient and outpatient responsibilities No ambulatory training responsibilities while on rotation and no rotation responsibilities during clinic week
  Team No functional team structure Each incoming intern assigned to a practice team from day 1
  Schedule Difficult to maintain patient continuity Schedules staggered so at least 1 member of each team is available in clinic at all times
  Coverage No clear mechanism for cross-coverage Practice teams divided into subcohorts so at least 1 team member is available in clinic at all times
  Resident patient hand-off No clear mechanism for transition Unnecessary; all members of patient's care team aware of patient's ongoing care plan
  Resident year-end hand-off No clear mechanism for transition Unnecessary because remainder of care team remains in place
  Clinic experience Disjointed for residents(eg, Mondays only, afternoons only) Seamless Monday through Friday clinic experience, morning through evening (with same true for rotation)
  Educational experience Disjointed for residents and preceptors Seamless with all members present from the beginning to the end of the day
  Duty hours No change No change
  Call scheduling No change No change, but free weekends during clinic weeks may increase opportunities for “golden weekends” (ie, no call or rotation duties)
×
Another advantage of X + Y scheduling is that assignment of patient care teams with staggered schedules eliminates many well-documented patient care issues resulting from year-end transitions when graduating residents’ patient panels are left to incoming interns.19,32-38 For each departing graduate in the X + Y scheduling model, the remaining team members who are already familiar with the patient panel rise in seniority and a new intern is added to the team, resulting in an “escalator” model with a 1-step annual increment. 
The most substantial advantage of this system, and perhaps the reason for its increasing popularity and success in GME, is its nearly universal customizable variability. Among the schedules that have already been devised and successfully instituted are 4+1, 6+2, and 3+1 versions.11,12,14,18 Osteopathic program directors and administrators are encouraged to examine the brief summary by Shalaby et al16 to see how they might be able to incorporate this scheduling method into their residency curricula. 
Challenges
As with any major structural change in curriculum design, preparation and planning are key to a successful transition. The guide by Shalaby et al16 provides a suggested timeframe and a list of topics to guide early discussions around planning a customized design. The author advises a July 1 start date because it initiates a new class without any scheduling expectations from the previous year. Clinic staff are advised to divide a dozen or more residents into patient care teams. This task needs only to be accomplished once. After the transition, each new patient can be assigned as needed. One of the greatest challenges for a clinic that does not already operate with such teams is the assignment of the clinic’s entire patient panel to various patient care teams. 
Physician preceptors may resist change, particularly in unopposed programs at smaller community hospitals, if they have used the same system for many years. As with any resistance to change, discussing the benefits of the proposed changes can clarify misunderstandings. In general, the individualized nature of this customizable method means that each program will face its own unique challenges. After initial implementation, administrators must view the new design as a work in progress and make individualized adjustments year after year as necessary to improve continuity of care, efficiency, and residency education. 
Limitations
The results of this study were based on a search of literature cataloged in the MEDLINE database via PubMed. Additional literature will be published as more programs implement this scheduling method, and future reviews may include searches of other databases. 
Conclusion
Starting in 2013, interest in the X + Y scheduling model has increased, and some allopathic institutions have begun to implement such curricular changes.39 To the author’s knowledge, the X + Y system that was first articulated by an osteopathic physician was an innovation well-aligned with the holistic principles of osteopathic medicine. However, this model has been more readily adopted by ACGME programs than by osteopathic GME programs. Although the horizontal clinical curriculum design is the norm today, it began as an innovation that transformed residency clinic scheduling to advance patient care and resident education nearly 20 years ago.5 In the same way, GME is now witnessing a transformation through X + Y scheduling. Let osteopathic GME not follow behind ACGME programs. Rather, let us have the foresight to lead this transformation. 
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Figure.
Flow chart of literature review process for studies with alternative residency clinic scheduling models.
Figure.
Flow chart of literature review process for studies with alternative residency clinic scheduling models.
Table.
Comparative Summary of Traditional Residency Clinic Scheduling vs X + Y Scheduling23
Element of Residency Clinic Traditional Scheduling X + Y Scheduling
  Responsibilities Conflicts between simultaneous inpatient and outpatient responsibilities No ambulatory training responsibilities while on rotation and no rotation responsibilities during clinic week
  Team No functional team structure Each incoming intern assigned to a practice team from day 1
  Schedule Difficult to maintain patient continuity Schedules staggered so at least 1 member of each team is available in clinic at all times
  Coverage No clear mechanism for cross-coverage Practice teams divided into subcohorts so at least 1 team member is available in clinic at all times
  Resident patient hand-off No clear mechanism for transition Unnecessary; all members of patient's care team aware of patient's ongoing care plan
  Resident year-end hand-off No clear mechanism for transition Unnecessary because remainder of care team remains in place
  Clinic experience Disjointed for residents(eg, Mondays only, afternoons only) Seamless Monday through Friday clinic experience, morning through evening (with same true for rotation)
  Educational experience Disjointed for residents and preceptors Seamless with all members present from the beginning to the end of the day
  Duty hours No change No change
  Call scheduling No change No change, but free weekends during clinic weeks may increase opportunities for “golden weekends” (ie, no call or rotation duties)
Table.
Comparative Summary of Traditional Residency Clinic Scheduling vs X + Y Scheduling23
Element of Residency Clinic Traditional Scheduling X + Y Scheduling
  Responsibilities Conflicts between simultaneous inpatient and outpatient responsibilities No ambulatory training responsibilities while on rotation and no rotation responsibilities during clinic week
  Team No functional team structure Each incoming intern assigned to a practice team from day 1
  Schedule Difficult to maintain patient continuity Schedules staggered so at least 1 member of each team is available in clinic at all times
  Coverage No clear mechanism for cross-coverage Practice teams divided into subcohorts so at least 1 team member is available in clinic at all times
  Resident patient hand-off No clear mechanism for transition Unnecessary; all members of patient's care team aware of patient's ongoing care plan
  Resident year-end hand-off No clear mechanism for transition Unnecessary because remainder of care team remains in place
  Clinic experience Disjointed for residents(eg, Mondays only, afternoons only) Seamless Monday through Friday clinic experience, morning through evening (with same true for rotation)
  Educational experience Disjointed for residents and preceptors Seamless with all members present from the beginning to the end of the day
  Duty hours No change No change
  Call scheduling No change No change, but free weekends during clinic weeks may increase opportunities for “golden weekends” (ie, no call or rotation duties)
×