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Teaching and Improving Quality of Care in a Primary Care Internal Medicine Residency Clinic

Holmboe, Eric S. MD; Prince, Leslie MPH; Green, Michael MD, MSc

Research Report

Purpose: Learning and applying quality of care principles are essential to practice-based learning and improvement. The authors investigated the feasibility and effects of a self-directed curriculum in quality of care for residents.

Method: In 2001–02, 13 second-year residents at two community-based outpatient clinics in the Yale University primary care internal medicine residency program were asked to participate in a trial of a quality improvement curriculum (intervention group). Thirteen third-year residents in the same residency program served as the comparison group. The curriculum consisted of readings in quality of care, weekly self-reflection with a faculty member, completion of a commitment to change survey, and medical record audits. Study outcome measures were patient level quality of care measures for diabetes, satisfaction with the curriculum, and self-reported behavioral changes.

Results: In the follow-up, patients of the intervention group were significantly more likely to have received a monofilament foot examination and baseline electrocardiogram than were patients of the comparison group. When comparing the change between baseline and follow-up, patients for the second-year residents showed significantly more improvement in hemoglobin A1c and LDL cholesterol levels and Pneumovax administration than did patients of the comparison group. All residents in the intervention group were highly satisfied with the curriculum. Thirty-five of 54 residents’ personal commitments to change were either partially or fully implemented six months after the curriculum.

Conclusions: A multifaceted curriculum in quality improvement led to modest improvements in the care of diabetic patients and meaningful changes in self-reported practice behaviors. Future research should include more focus on the microsystems of residency outpatient experiences.

Dr. Holmboe is vice president for evaluation research and director of clinical performance services, American Board of Internal Medicine, Philadelphia, Pennsylvania. At the time of this study, Dr. Holmboe was associate professor of medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.

Mr. Prince is a second-year medical student, University of the West Indies, Kingston, Jamaica. At the time of this study, Mr. Prince was a student in the Masters of Public Health Program, School of Public Health, University of Connecticut, Farmington, Connecticut.

Dr. Green is associate professor of medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.

Correspondence should be addressed to Dr. Holmboe, American Board of Internal Medicine, Suite 1700, 510 Walnut Street, Philadelphia, PA 19160; telephone: (215) 446-3609; fax: (215) 446-3636; e-mail: 〈eholmboe@abim.org〉.

© 2005 Association of American Medical Colleges