Fancher, Tonya L. MD, MPH; Keenan, Craig MD; Meltvedt, Caitlyn; Stocker, Timothy MD; Harris, Tracie MD; Morfín, José MD; McCarron, Robert DO; Kulkarni-Date, Mrinalini MD; Henderson, Mark C. MD
Dr. Fancher is assistant professor of internal medicine and associate program director, University of California, Davis, Sacramento, California.
Dr. Keenan is associate professor of internal medicine and senior associate program director, University of California, Davis, Sacramento, California.
Ms. Meltvedt is junior research specialist, Department of Internal Medicine, University of California, Davis, Sacramento, California.
Dr. Stocker is clinical faculty of internal medicine, Kaiser, Los Angeles, California.
Dr. Harris is assistant health science clinical professor, University of California, Davis, Sacramento, California.
Dr. Morín is assistant professor of nephrology, University of California, Davis, Sacramento, California.
Dr. McCarron is assistant professor of psychiatry, University of California, Davis, Sacramento, California.
Dr. Kulkarni-Date is assistant professor of endocrinology, University of Texas Medical Branch Austin Programs, Austin, Texas.
Dr. Henderson is professor of internal medicine and program director, University of California, Davis, Sacramento, California.
Please see the end of this article for information about the authors.
All correspondence should be addressed to Dr. Fancher, Department of Internal Medicine, University of California, Davis, 4150 V Street, Suite 3100 Patient Support Services Building, Sacramento, CA 95817; telephone: (916) 734-4091; fax: (916) 734-2732; e-mail: Tonya.Fancher@ucdmc.ucdavis.edu.
First published online December 16, 2010.
The popularity of pursuing a career in primary care has been declining for decades.1–5 In 2008, only 2% of U.S. medical school graduates planned careers in ambulatory general internal medicine.6 The provision of high-quality primary care is further compromised by high rates of uninsured patients (one in five in California).7 Several reports project a substantial primary care physician shortage in the United States,8,9 heightening concerns about access to care in medically underserved communities10 and for the nation's uninsured.5,11
As a means to reinvigorate internal medicine training, the Association of Program Directors in Internal Medicine (APDIM) has recommended tailoring the third year of residency to allow exploration of individualized career interests, such as ambulatory medicine, hospital-based medicine, biomedical research, subspecialty fellowship, public health, health policy, or care for underserved populations.12,13 Other interventions that might bolster the ambulatory general internal medicine workforce include community–academic partnerships (which also improve care of the underserved),14 improvements to the ambulatory practice environment,6 additional training on how to care for patients with psychosocially complex problems,15 and opportunities for continuity of care, mentorship, and community-based training.16
An intervention along the lines recommended by the APDIM occurred in 2005 when the University of California, Davis School of Medicine (UC Davis) Department of Internal Medicine partnered with the Sacramento County Department of Health and Human Services to create the Transforming Education and Community Health (TEACH) Program. The TEACH Program is a competitive residency track for third-year residents who are interested in delivering comprehensive primary care for Sacramento County's uninsured population. The TEACH Program features continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares the residents to provide coordinated care for vulnerable populations. Sacramento is the most racially and ethnically integrated major city in America,17 and thus UC Davis is surrounded by an unusually diverse community, in which nearly 20% of residents are foreign born, 50% are Hispanic/Latino or black/African American, and one in four speaks a language other than English at home.18
We hypothesized that a connection to the community and attention to resident practice satisfaction and chronic disease management could stimulate interest in primary care and improve the quality of care for the medically indigent. In this article, we describe our experience with the TEACH Program, its curriculum, resident outcomes, barriers to continued implementation, and future directions for the program. The authors include six TEACH faculty (T.L.F., C.K., J.M., R.M., M.K.D., M.C.H.), a TEACH resident (T.S.), program graduate (T.H.), and key nonclinical leader (C.M.). This project was approved by the UC Davis institutional review board.
Overview of the TEACH Program
The UC Davis internal medicine residency has a total of 82 positions in its categorical and primary care programs. Program leadership includes the program director and three associate program directors. In the winter of their second year, residents interested in the TEACH Program submit an application describing their qualifications and career plans. Up to eight second-year residents (about 30% of the class) apply for the TEACH Program each year. A committee of faculty and TEACH Program graduates selects the top five applicants, who begin the TEACH Program in July of their third year. We had originally planned to accept four residents per year, but interest in the program prompted us to expand to five, a number we have since maintained. From the time of its inception in 2005, 25 residents have graduated from the TEACH Program.
Each TEACH resident spends 16 weeks or four blocks on the categorical internal medicine services (intensive care unit, elective, ward, night float/vacation) and 36 weeks or nine blocks on TEACH (see Figure 1). A TEACH block includes one to two weeks on the TEACH ward service and two to three weeks on the TEACH ambulatory service. At any one time, one TEACH resident is on the ward service while the others are on the TEACH ambulatory service or on categorical internal medicine rotations. By comparison, a UC Davis third-year, categorical resident does five inpatient blocks (intensive care unit, three wards, and coronary care unit), five elective blocks, two ambulatory blocks, and one night float/vacation block.
TEACH ward service
The TEACH ward service includes one third-year resident, one third-year medical student, and an attending physician. The non-TEACH ward services include a resident, two interns, and two to three medical students. By not including interns, TEACH residents assume a first-contact role with patients, which promotes patient ownership and enhances the doctor–patient relationship—factors that are especially important for patients who do not have a primary care physician. The TEACH residents more frequently impanel ward service patients into their own continuity clinics than do the categorical residents (who treat primarily patients who already have established primary care providers).
TEACH residents admit new patients every day from 7:00 am to 4:00 pm, and the team census is limited to eight patients. Patients admitted after 4:00 pm are admitted by a night float resident and transitioned to the TEACH ward service the following morning. TEACH residents do not have clinic responsibilities when assigned to the TEACH ward service, which minimizes the perceived “burden” associated with competing clinic duties. Categorical residents continue to have clinic duties during ward blocks.
TEACH ambulatory service
The second component of the TEACH Program, ambulatory service, includes continuity and subspecialty clinics, a TEACH didactic curriculum, and a nonclinical community-based experience. The TEACH clinics are located at the Sacramento County Primary Care Center, which is located in a Health Professional Shortage Area and provides the bulk of indigent care in the county. It serves a population that is 95% low income, 78% nonwhite, and 50% non-English speaking. The most common non-English languages spoken are Spanish (50%), Vietnamese, Hmong, and Russian. Having any insurance disqualifies patients for county health benefits, so most patients are under age 65. As in other indigent populations, there are high rates of comorbid mental and physical illness. The top five primary diagnosis codes for the clinic are diabetes, acute and chronic pain syndromes, hypertension, depression, and substance abuse.
The five TEACH residents provide care for approximately 5,000 of the over 160,000 visits to the Primary Care Center each year. Residents care for their individual patient panels and cover clinic duties for other TEACH residents on inpatient services, similar to a group practice model.
On average, TEACH residents have four continuity clinics and three subspecialty clinics per week. The concentrated time in clinic facilitates continuity of care for patients recently discharged from the hospital, allows patients to be seen almost daily (if needed), and provides an uninterrupted resident ambulatory experience. TEACH clinic templates include both same-day and scheduled appointments. TEACH residents are supervised by county physicians and UC Davis faculty. Most of the TEACH residents also maintain a small continuity panel at the UC Davis General Medicine Resident Clinic, which allows indigent patients who acquire federal insurance coverage such as Medicare or Medicaid to transfer to UC Davis and to continue to receive care from the TEACH residents.
The TEACH Program introduced subspecialty nephrology, endocrinology, and medicine–psychiatry clinics at the Primary Care Center. The twice-monthly nephrology clinic provides continuity for patients with advanced chronic kidney disease, especially as they transition to renal replacement therapy (e.g., hemodialysis). In the weekly endocrinology clinic, TEACH residents see patients with type 1 and type 2 diabetes and endocrinology referrals from other Sacramento County providers. Dual-certified internal medicine and psychiatry physicians supervise a weekly medicine–psychiatry clinic that emphasizes patient self-management, motivational interviewing, brief cognitive behavioral therapy, and interprofessional collaboration.
TEACH residents attend a weekly half-day seminar shared with the primary care track residents. The seminar topics include principles of evidence-based medicine, resident-led journal clubs, clinic-based procedures training, quality improvement, medical billing, primary care psychiatry, motivational interviewing, health care disparities, and health policy. A series on cultural humility and cross-cultural communication was recently introduced. TEACH residents continue to attend the weekly internal medicine residency didactics.
In addition to the Sacramento County Department of Health and Human Services, the TEACH Program collaborates with the Communities and Physicians Together (CPT) Program, a 10-year partnership between UC Davis and local grassroots community organizations, which teaches residents to partner with local communities to improve the health of the population.19 During the first three months of their internship, all internal medicine interns spend one nonclinical week in the local neighborhood. Instead of “tourism” experiences such as visiting free clinics or social agencies,20 interns learn about various organizations from the perspective of the community members21 and are introduced to asset-based community development.22 All TEACH residents develop a CPT community project and spend up to one half-day per week on its implementation and evaluation.
Outcomes to Date
Resident workforce outcomes
Many residents pursue subspecialty fellowships two or more years after residency.23 We therefore reported practice specialty as of the second year following graduation (except for the class of 2010). Of the 126 internal medicine residents at UC Davis since 2006, 16 (64%) TEACH graduates practice general internal medicine, 17 (74%) primary care graduates practice general internal medicine, and 23 (29%) categorical graduates practice general internal medicine (see Figure 2). By comparison, 33% of internal medicine graduates nationwide practice general internal medicine.23
Over the past three years, the percentage of TEACH graduates choosing general internal medicine has steadily increased, from 60% to 100%. Forty-seven percent of the TEACH graduates who applied from the categorical program went on to practice general internal medicine. Of all of the TEACH graduates who have been in practice for more than one year, 35% are practicing in underserved communities (data are not available for the non-TEACH residents).
Resident preparedness and job satisfaction
Residency graduates are surveyed at the end of each academic year, and so we have used survey data from the 2006–2009 graduates. Of the 20 TEACH graduates over this period of time, 12 (60%) completed the annual survey. Of the 63 categorical and 17 primary care graduates during the same time period, 16 categorical and 8 primary care 2007 graduates did not receive surveys; 29 (62%) and 6 (67%), respectively, of surveyed residents completed the survey. We focused our data collection on outcomes where national comparisons were available. Our exploratory analysis included the Global Job Satisfaction composite measure from the Physician Worklife Study24 (see Appendix) and Blumenthal and colleagues'25 survey on resident preparedness for clinical practice.26 The TEACH residents reported statistically significant higher levels of global job satisfaction than other UC Davis internal medicine residents or practicing general internal medicine providers (see Table 1). Compared with a national sample of internal medicine residents, all UC Davis internal medicine residents reported that they felt better prepared to manage chronic illnesses such as diabetes, depression, and asthma (but these differences were not statistically significant). We also asked the four Patient Care Issues (PCI) questions from the Physician Worklife Study24 but did not use the composite measure because of low item correlation (Cronbach alpha 0.43). On the PCI, the TEACH residents reported the lowest levels of feeling adversarial, overwhelmed, or that time pressures kept them from developing good patient relationships (data not shown) compared with categorical and primary care residents.
Patient care outcomes
As a resident quality improvement effort, one TEACH resident (T.S.) used the American Board of Internal Medicine's Practice Improvement Module to assess diabetes care in the TEACH clinic.27 When compared with Health Effectiveness Data and Information Set metrics,28 TEACH residents outperformed managed care plans for most process and outcome measures (hemoglobin A1c testing, fasting lipid testing, nephropathy assessment, hemoglobin A1c <9% and <7%, blood pressure <140/90 mm Hg and <130/80 mm Hg).
Challenges to Implementing and Expanding the TEACH Program
Introducing a new program requires significant trade-offs in other aspects of the larger internal medicine program. Adding a new inpatient service without simultaneously increasing the total number of residents has resulted in the categorical residents doing more inpatient rotations. Prospective TEACH applicants were concerned initially about having fewer elective months than categorical residents, but this issue has been addressed with longitudinal subspecialty clinics. Finally, strong support from the departmental leadership for the TEACH Program's mission to promote continuity and quality of care for the uninsured was critical.
Tracking patient care outcomes and follow-up is always difficult. Because patients can, theoretically, be admitted to any local hospital, measuring changes in hospital admission rates associated with the program is challenging. Our ability to track outpatient outcome measures has been hampered by rapidly shifting county clinic eligibility due to local policy changes (e.g., the County of Sacramento recently eliminated health care coverage for undocumented immigrants), fluctuating patient employment/unemployment status leading to significant migration into and out of the county health system, and loss of personnel due to the California state budget crisis.
Finally, the tenuous federal support for Title VII Health Professions Programs remains an ongoing challenge for the program.
Outcomes and the Future of the TEACH Program
In this article, we describe a residency track focused on the care of the medically indigent. Compared with national internal medicine data, TEACH graduates are more likely to choose general internal medicine and to practice in underserved settings. Compared with their peers, TEACH residents are more satisfied with the practice of medicine and less negative about patient care issues. Categorical residents who enroll in the TEACH Program may strengthen their interest in underserved care, be stimulated by the unique structure of TEACH ward service, or discover a late-blooming interest in primary care. This educational program complements other efforts to restore interest in general internal medicine and increases the number of physicians practicing in underserved communities.29 We acknowledge that other factors such as excellent role models6,30–32 and self-selection (of residents already committed to general internal medicine) also may have influenced our career choice outcomes.
The TEACH Program trains residents to provide high-quality care to a diverse population. An Institute of Medicine report highlights the need for quality and equity in health care.33 Uninsured patients are more likely to delay seeking care for serious or chronic medical conditions, report poor health status, and forego necessary care for potentially serious symptoms.34 Problems with continuity of care from inpatient to outpatient settings are associated with a rise in medical errors and increased risk of rehospitalization and poor communication.35–38 Although we have not been able to measure improvement in these outcomes, the inpatient-to-outpatient continuity has improved communication between the county clinics and university physicians and is likely to foster improved outcomes.2 The TEACH residents provide diabetes care on par with or better than national quality benchmarks.
As of 2009, over 6,200 Health Professional Shortage Areas were home to 65 million people.39 Medical schools and residency programs can play key roles in encouraging and preparing physicians to practice in underserved areas.29 Thirty-five percent of TEACH graduates work in underserved communities compared with 3% to 25% of internal medicine graduates nationwide (depending on the definition of an underserved setting).5
Several health reform measures have been recommended to improve primary care access and equity including incentives for the establishment of primary care ambulatory training programs that provide quality care to the expanding underserved population,14 support for programs that specifically recruit and train students interested in working in underserved areas,40,41 and methods to address other disincentives for primary care careers such as the income gap,42 work–life balance,43 and educational debt.44 Federal funding of Title VII (for physicians, physician assistants, and dentists) and Title VIII (for nurses) training programs have addressed some of these issues and have been effective in promoting primary care, underserved care, and cross-cultural care.5,45–47 Yet this funding remains threatened on a yearly basis. The TEACH Program provides further evidence that funding for such programs should be continued or enhanced.
Our resident workforce data should be interpreted with a few caveats. The resident survey completion rate was low and may represent only those residents with the strongest (and perhaps most positive) views. Over the past eight years, approximately 50% of UC Davis internal medicine residency graduates chose general internal medicine. We would expect to see the influence of the TEACH Program (a third-year track since 2005) on career choice beginning with the 2008 graduates. Although these are early findings, we have seen an increasing percentage of TEACH graduates choose general internal medicine (currently 100%).
The TEACH Program influences residents to choose general internal medicine careers, bolsters the physician workforce in underserved communities, and models community-based training for other institutions.48 Programs that shift training to ambulatory settings and emphasize continuity of care may be particularly attractive to younger physicians.43 We hope that our emphasis on continuity of care, uninterrupted ambulatory time, community partnership, and a group practice model will ultimately lead to fewer hospitalizations and better health outcomes for vulnerable patients.
The authors wish to thank Dr. Fred Meyers for his ongoing support and vision and also to thank Mrs. Kathy Bers for her statistical support.
Drs. Fancher, Harris, Morfín, McCarron, Keenan, and Henderson and Ms. Meltvedt are supported by a Residency Training in Primary Care grant from the Department of Health and Human Services (HRSA D58HP05139). Dr. Kulkarni-Date was previously supported by this grant.
Dr. Henderson receives book editorship royalties from McGraw-Hill Medical Publishing.
This project was approved by the UC Davis institutional review board.
Portions of this project were previously presented at the Society of General Internal Medicine annual meeting, Pittsburgh, Pennsylvania, April 9, 2008, and the Association of Program Directors in Internal Medicine annual meeting, New Orleans, Louisiana, October 2006.
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