The tension between providing patient care and training future health care providers is a widespread concern within academic medical centers. This constant exercise in prioritization, compounded by abbreviated inpatient stays and increasingly limited outpatient encounters to generate revenue and maintain efficiency, can result in an overamplified expectation of expediency that can supersede the reflection and in-depth learning that trainees need.
For more than 25 years, the Ambulatory Diagnostic and Treatment Center (ADTC) in the Veterans Affairs (VA) Boston Healthcare System has functioned as an outpatient referral clinic and served as an internal medicine residency and medical student ambulatory clerkship rotation site. The veterans who receive care at the ADTC have a range of diagnoses, and their treatment focuses on their semiexigent needs and on the follow-up care required, both of which provide rich opportunities for education.
Given recent media reports about delays in veterans’ access to VA care throughout the country and the emphasis on core competencies in medical student and resident education, in this article, we reexamine a model that our colleagues described decades ago,1 which aims to prioritize education while continuing to provide optimal, accessible patient-centered care.
About the ADTC
The ADTC was developed in 1988 during a nursing shortage in Boston when the Boston VA Medical Center had to close an inpatient ward. At the time, some observed that patients were being admitted to the hospital for expedited evaluation and management of active problems because the ambulatory care system, particularly the primary care system, could not accommodate their care.1 In response, attendings and housestaff from the nonoperational inpatient ward were put to work with a new purpose—to provide care in an outpatient clinic with an inpatient mind-set. The ADTC aimed to accomplish what most medical centers had yet to do—resolve complex cases worthy of expedited assessment without admitting patients to the hospital. This model of delivering outpatient care on an inpatient schedule with rapid access for patients to diagnostic testing and input from consultants optimized triage, treatment, and resolution. Caring for a limited number of patients with active clinical issues rather than stable chronic conditions typical of the patients in many ambulatory continuity settings provided rich educational opportunities for trainees.
Personnel and patient flow
The ADTC is staffed by a team of one attending physician, three (postgraduate year 2 or 3) internal medicine residents on two- to three-week rotations, and one fourth-year medical student from the Boston University School of Medicine on a three- to four-week rotation. The attending, one of a group of about seven who rotate through the clinic on two- to four-week blocks, is a general internal medicine faculty member at the Boston University School of Medicine. Attendings also actively participate elsewhere in the VA Boston system as inpatient hospitalists, primary care providers, emergency department physicians, and subspecialty clinicians (e.g., infectious disease, palliative care, women’s health), bringing a breadth of experience to the ADTC.
Each year, 11 medical students on their ambulatory medicine clerkship are randomly assigned to the ADTC. In addition, about 80% of postgraduate year 2 and 3 internal medicine residents in the VA Boston system rotate through the clinic. Two of the seven chief medical residents are selected, from those who express interest each year, to participate as attendings. They must complete a mandatory coattending training period with ADTC attending faculty. During this period, the chief residents learn to address the systems issues they will face when supervising the clinic on their own. Given their relative inexperience with the medical center as a whole, this process is meant to ensure that they know how to properly triage patients who are referred to the ADTC.
Referring providers in the VA Boston system (typically inpatient hospitalists, emergency department physicians, and primary care providers) page (or contact via secure e-mail after hours) the ADTC attending to request an appointment. The referral process aims to balance the immediate needs of the patient, the resources that could best serve that patient and the availability of those resources, and the educational value of the referral. ADTC attendings, who are familiar with the resources of the VA Boston system, can guide the requesting provider to the appropriate next steps if the clinic is deemed inappropriate; for example, if the patient is too ill or frail to be seen repeatedly in an outpatient care setting and/or requires a procedure not performed in the clinic.
Handoffs and continuity of care
As the staff and trainees at the ADTC change frequently, a Health Insurance Portability and Accountability Act–compliant, multiuser, internal server-based database is used; it contains a list of active patients “admitted” to the clinic (i.e., those pending evaluation and/or being actively managed). Any patient for whom the ADTC has ordered medications, tests, follow-up appointments, or other services that are still pending is kept on the list of active patients. The ADTC “discharges” patients when both the providers and the patients are satisfied that the issues for which the patients were referred have been resolved, akin to hospitalists when discharging inpatients. As part of the handoff process, communication with primary care providers occurs via secure e-mail or as a request to cosign the electronic health record progress note, which allows the primary care provider to acknowledge receipt of the information about the care the patient has received.
Unique Patient Care Experience
Patient care services and types of referrals
The ADTC evaluates a variety of patients. Those who are referred to the clinic often have undiagnosed systemic disorders with broad differentials or they suffer from poorly managed new or known chronic diseases. Symptoms such as unexplained weight loss, edema, or dyspnea on exertion, or diagnoses such as poorly controlled diabetes, severe or refractory hypertension, or congestive heart failure with acute onset chronic kidney disease, are common and often benefit from more intensive management, like that provided at the ADTC.
The physical location of the clinic within the medical center and its modest patient volume also allow for the care of other patients within the VA Boston system who have specific clinical needs—for example, the posthospitalization evaluation of “at-risk” patients, the medical clearance of patients being enrolled in long-term psychiatric/substance use programs, the evaluation of immediate-priority veterans returning from active service awaiting primary care, on-call perioperative risk optimization for patients assessed in the adjacent surgical preoperative center, and interim care for visiting veterans who live elsewhere.
Care in the ADTC is intended to address a specific episode of illness or problem; thus, the case is concluded when symptoms improve or a formal diagnosis and plan are in place. The clinic carries out this model of care using a series of closely spaced outpatient appointments that are frequently much longer than a typical ambulatory appointment. For the most complicated situations, visits can last 90 minutes or more, allowing for a complete history and physical examination that includes an exploration of psychosocial issues. Ideally, patients are evaluated, worked up, then “discharged” within two weeks; this model bypasses the space requirements and cost inherent in providing inpatient care as well as the space and time limitations of busy primary care providers.
Patients referred to the clinic are triaged via direct physician-to-physician communication, which optimizes handoffs and ensures their suitability for the ADTC. The ease with which patients join the clinic’s panel minimizes waste, lessens the likelihood that they will seek emergency department care for routine issues, and aims to reduce readmission rates for recently discharged, complex patients and to increase patient and health care provider satisfaction. Referrals come from emergency and urgent care services, subspecialty clinics, as well as from primary care providers seeking either a more detailed second opinion on a frustrating clinical dilemma or simply the more intensive short-term care the clinic provides.
Balancing patient care and education
The number of patients seen in the ADTC is modest; hence, the clinic is not frenzied as some primary care clinics are and so can provide VIP-level access for all patients. Patients generally are seen within three days of referral, based on acuity, with follow-up appointments (if necessary) occurring in the same time frame. The clinic’s physical space is intended to optimize both patient care and education, not higher relative value units. The light patient schedule allows residents to research their patients’ clinical problems and test results both independently and through discussions with specialists as needed. The clinic team strives to function as an extension of the primary care provider and/or specialist without the patient having to physically attend a subspecialty appointment elsewhere.
The restructuring of primary care and subspecialty care clinics and the integration with home-based primary care, telehealth, and visiting nursing services in the years since its inception have affected the patient volume and structure of the original ADTC model. Yet, the clinic continues to augment, assist, and absorb patients from other continuity clinics. Through their role as outpatient intensivists, ADTC clinicians continue to bridge inpatient and outpatient care as well as primary and specialty care. Over the same time period, the volume of clinical data available for each patient and the options for imaging modalities, laboratory tests, and treatment have dramatically increased. This change has necessitated that ADTC trainees receive extra time to adequately consider the clinical problems of their patients and to engage in guided and self-directed learning.
Unique Educational Experience
The ADTC provides an intensive training environment, with a 1.5-hour conference and 2.5-hour slot for patient care each morning. The ratio of didactic sessions to patient care time and/or time devoted to discussing patient care during morning report each day is adjusted based on the flow of patient referrals and the complexity of the cases received. Such changes are possible because the attending, who works closely with the medical support assistants who schedule patients into the clinic, has total control of the approval and flow of patients and the spacing of appointments and is able to anticipate the relative amount of time necessary for each visit.
Residents occasionally review and present on the relevant literature prior to meeting with patients to ensure that they have the most up-to-date data informing their evaluation and assessment. Each resident, with or without the medical student, evaluates one to two patients each morning; this evaluation includes a thorough discussion with her or his preceptor. Afternoon schedules are light and include didactic sessions and time for personal reading and outreach to primary care providers and/or specialists as needed. No weekday evening or night shifts are scheduled during this rotation, affording residents additional time to reflect on the day’s diagnoses and to scrutinize the literature related to their patients’ clinical problems, a luxury not readily available during other rotations. The following morning, residents present their cases and share lessons learned from the literature they reviewed. Decisions based on superficial or dictated knowledge during other rotations become decisions based on a deeper exploration of that knowledge during the ADTC rotation. Residents also learn to value the expertise of consultants (sometimes in real time), to appreciate the stability (or lack thereof) of uncertain clinical scenarios, to fine-tune evidence-based decisions, and, in best-case scenarios, to unmask ambiguous diagnoses that could elude a clinician in a more resource-limited setting.
Unique educational qualities
What sets the ADTC apart from other clinics? First, most continuity clinics in primary and specialty care may not allow adequate time for literature-based didactics or for residents to order tests and be present for the results and for the ongoing management of those results. The ADTC structure provides residents with time and resources for these activities; patient care slots are protected, and an inpatient-like priority is placed on ancillary testing requests so that a resident who suspects, for example, a diagnosis of amyloidosis, can actually make that diagnosis during her or his brief time in the clinic. Additionally, as the clinical status of some patients referred to the clinic hovers between volatility and stability, residents are able to appreciate the unique nuances of this state, which augments their clinical skills for future encounters—they learn to determine when it is best to admit a patient and when it is not. Because a detailed literature review and morning conference are expected, residents are given opportunities each day to practice these skills, emphasizing competence in these areas.
Finally, unlike during other rotations where clinical care takes priority over education, during the ADTC rotation, residents are encouraged to be present throughout medical students’ patient visits, allowing them to provide real-time feedback on students’ clinical skills. Emphasizing the acquisition of these skills is meant to deepen the clinically relevant learning that occurs. The result is an educationally intensive rotation for trainees and a clinically intensive care episode for patients.
Medical students’ and residents’ performance is assessed using the Accreditation Council for Graduate Medical Education core competency framework and the PTRIME (Professional, Team/Systems, Reporter, Interpreter, Manager, Educator) structure,2 and data are aggregated for analysis and feedback. Ambulatory medicine clerkship directors and residency program preceptors assess this information and make decisions on promotion or remediation as appropriate. Residents also complete evaluations that are used, along with their quality improvement projects, to implement changes to the program. The rotation consistently ranks highly in comparison with the other core internal medicine rotations and with respect to the following items: “the setting provided teaching opportunities for the trainee” and “the setting provided opportunities to learn about the organization, access, financing, and delivery of care in the community and the institution.”
The following quotations from residents’ evaluations are representative of the feedback received about the program:
I enjoyed the academic nature of ADTC. I think it serves as a good model for the rest of our rotations in terms of creating a culture of reading, reviewing evidence and group learning.
Outstanding rotation; one of the few times that residents were able to focus primarily on academics, and on reading latest literature. Allowed residents to truly learn and manage all of a given patient’s issues in a comprehensive manner.
This is an absolutely fabulous rotation. I can’t even count the number of times I wanted to look things up about a patient while on the wards and just didn’t have the time or energy to after I got home. This rotation not only allows you to do that, but makes it mandatory!
Similarly, during their lengthy clinic visits, patients have expressed their satisfaction with the ADTC model.
The number of outpatient visits for veterans is expected to increase dramatically in the coming years.3 In addition, several recent editorials have commented on the derailment of the VA’s mission of providing timely access to dependably high-quality care, leading to calls to return to this focus.4 As a result, the VA is heavily recruiting physicians across the country, especially within divisions of primary care, to meet clinical demand. A low-volume, high-intensity clinic like the ADTC is not suited to meet this demand for increased overall access to care. However, it can augment the services provided by a busy primary care and subspecialty workforce (see Chart 1).
The business model of the ADTC rotation works within the VA because residents’ salaries are paid through the VA’s office of academic affairs and the additional funds provided by the Veterans Equitable Resource Allocation offset the costs of attendings’ teaching time; they are not dependent on direct clinical revenue. We are unaware of similar educational models at other VA facilities or elsewhere, making the ADTC unique. Periodically, hospital administrators question the rotation because of the clinic’s modest patient volume relative to the space and staff deployed. Yet, since its inception, the rotation has been vigorously defended by leaders from the Boston University School of Medicine Department of Medicine and by the affiliated program directors because of its unique and high educational value. We do not have the data to perform a formal cost-effective study, nor can we say with precision how many hospitalizations are avoided by the ADTC model of care. Anecdotally, however, urgent care and emergency department physicians tell us that more patients would have been admitted to the hospital if the clinic did not exist.
Many have called for innovations in internal medicine training, particularly in the ambulatory setting.5–9 The ADTC provides trainees with time to interact and communicate effectively with patients and with their supervisors. Adults learn best when motivated by problems that need solving,10 and professionals require time to reflect on their work and actions to further develop their professional skills.11,12 The ADTC provides a clinical and educational environment with these characteristics. Even when caring for patients presenting with common disorders, in this type of environment, trainees can find value in consolidating and deepening their understanding of, for example, hypertension or diabetes management, and becoming expert internists.
The ADTC has evolved over the years to serve a number of unique roles for the medical center while maintaining an intensive educational environment. As the balance between providing clinical care and educating trainees has changed, the ADTC has endured. Today, the accessibility and applicability of the services the clinic provides in an accountable care organization like the Veterans Health Administration are selling points for this model. Patients’ clinical needs and trainees’ educational needs will continue. We believe that other academic health centers can learn from the ADTC model and adapt its structure in settings where accountable care organizations and education collide.
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