AAIM Perspectives
X + Y Scheduling Models in Internal Medicine Residency Programs: A National Survey of Program Directors' Perspectives

https://doi.org/10.1016/j.amjmed.2017.09.012Get rights and content

Introduction

Over the last decade, there has been a national call to transform internal medicine training to adapt to changes in health care. The lack of emphasis on ambulatory experiences within residency programs will have potential detrimental effects on training residents for office-based care and may influence resident career choices away from primary care–specific fields.1, 2, 3, 4, 5, 6, 7, 8, 9 Although the majority of health care is delivered in ambulatory settings, a large portion of internal medicine residency training has traditionally occurred in the inpatient setting.10, 11, 12

In July 2009, the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Internal Medicine called for significant changes in resident continuity clinic training, including increased requirements for ambulatory experience to help improve the focus on ambulatory care and to reduce the tension between conflicting inpatient and outpatient patient care responsibilities that may occur in the traditional weekly scheduling model.13 In response to the ACGME mandate, a number of internal medicine programs have transitioned to a variety of “X + Y” scheduling models. In these models, the “X” represents inpatient or nonambulatory rotations that alternate with dedicated ambulatory (or “Y”) blocks. The first published X + Y model was a “4 + 1” model,14 but since then, numerous programs have developed their own versions, including 3 + 1, 4 + 2, and 6 + 2 models, and other hybrids.15, 16, 17, 18 Several studies of X + Y models have demonstrated decreased fragmentation of care, increased resident satisfaction, and increased resident perceptions of visit continuity.16, 19

There are no national data to determine how many programs have adopted or are considering change to an X + Y model. Furthermore, residency program director experiences with such models, including their perceived benefits and challenges, have not been explored at a national level. We conducted a survey of 396 internal medicine residency program directors as part of the Association for Program Directors in Internal Medicine (APDIM) Annual Survey. The goals of the “X + Y” survey questions were to evaluate the extent to which programs have adopted X + Y scheduling models, describe program director experiences with the models, and understand the perceived impact of the X + Y models on residency programs.

Section snippets

Survey Creation and Administration

The APDIM administers an annual survey of internal medicine program directors. The goal of the survey is to develop a longitudinal database that can help inform organizational policies and initiatives and update members on important topics in graduate medical education.20 For the 2015 survey, email notifications with program-specific hyperlinks to a web-based questionnaire were sent in August 2015 to program directors of 368 APDIM member programs, representing 93% of the 396 ACGME-accredited

Results

Of the 396 internal medicine programs in the United States, 368 are member programs of the APDIM. Of that membership, 227 returned surveys for a 62% response rate. For the section on X + Y schedules, there were 226 responses, yielding a 61% response rate for that specific section. Demographics between responders and nonresponders showed no significant differences in all domains with the exception of a higher response rate from programs in the Northeast (37%) versus the rest of the country (29%).

Discussion

There has been increasing interest in X + Y scheduling models for internal medicine residency training. This article represents the largest and most comprehensive attempt at identifying how many programs are using such models, identifying why programs switched to this model, and what perceived benefits and challenges the models pose. To our knowledge, this is the first national study on the prevalence and perception on X + Y models.

Forty-four percent of internal medicine residency programs are

Conclusions

The development of X + Y models over the last decade represents a large shift in the structure of internal medicine training programs. A large portion of programs have decided that the benefits of these models outweigh the obstacles and have converted to such models. It is our belief that the growth of these models will continue and may ultimately become the dominant model for residency scheduling. As the collective knowledge about such models expands, we anticipate advances in technology and

Acknowledgements

The authors thank Judy Shea, PhD, at the Perelman School of Medicine at the University of Pennsylvania for her contributions in data analysis for this manuscript.

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    Funding: None.

    Conflict of Interest: MS has received consultation fees from internal medicine and pediatric residency programs desiring to implement X + Y scheduling models into their residency programs.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

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