The Ambulatory Long Block: Resident Training in a High-Functioning Clinical Microsystem

Last year, the AAMC held its first-ever Readiness for Reform Innovations Challenge, to which academic medical centers  across the country submitted best practices. Three winning institutions were honored at the 2011 AAMC Annual Meeting in November, winning $5,000 each for their innovative programs. The Wing of Zock is featuring posts from two of the winners, as well as a post from the chair of the selection panel, in a series highlighting the successes and learning opportunities that came from developing these initiatives and entering the Innovations Challenge. The winning submissions, as well as all of the other entries, can be seen in their entirety on the AAMC iCollaborative.

By Eric Warm, MD, University of Cincinnati College of Medicine

The Ambulatory Long Block program stemmed from our goal to put more continuity back into resident training as we sought to improve care and education in our ambulatory center. In ambulatory care, continuity of care is critical, as we show that we are there for our patients and begin to build a relationship with them. The Long-Block occurs from the 17th to the 29th month of residency. Long-block residents follow 120-150 patients each, have office hours three half-days per week on average, and respond to patient needs (by answering messages, refilling medications, etc.) daily. During this year residents have limited inpatient call duties, with the balance of their time spent on consultative rotations.

We had been involved previously in the AAMC’s Academic Care Collaborative, a 15-month program during which we learned skills to improve care in the ambulatory setting. Based on what we learned, we knew that what was missing from our resident teaching system was the ability of residents to deliver true continuity to their patients. This was a problem because outpatient medicine was always subservient to in-patient medicine. There was always this demand that the residents had to give back to the wards, back to the in-patient setting, so they could never be fully present in any moment. It was really tough for our residents to give sustained attention to any of the patients. Further, residents were there a tenth of the time, but what happened the other nine-tenths of the time wasn’t their issue.

We began to brainstorm ways to keep residents focused and engaged in the clinic. We considered taking them out of the clinic and going to a short-block model, with a month in the clinic and a month out, but that wasn’t realistic for patients: Patients don’t get sick only when you’re there; they get sick when they get sick. We realized that we needed to develop a way for doctors to participate in a group practice for a year, a sufficient amount of time to emphasize continuity.

We have practiced the long block for six years now, and there are many advantages to residents. It is a dramatic change and it is not for everybody, but the results outweigh any consequences. It has changed the way we recruit; now we look for people who know their science but also can talk to patients in meaningful ways. Our hospital emphasizes  physicians’ strong in-patient and outpatient relationships; we attract people who share our patient-centered relationship philosophy.

It was important to find the right people to pick up the work the residents won’t be doing while they are in the clinic for a year. We got our hospitalist service up and running early in the program. We also engineered an attitudinal shift among our faculty; not all of them supported the long block  initiative at first.

People always ask me what I think is the most important outcome of the long block initiative. If I were to emphasize two things above anything else, it would be team first, data second. Every Monday, all the residents, the nurses, and the clinic faculty meet and we always start with a patient story. It can be good or bad or funny. Then we share patient data, discuss problems, and brainstorm where we can improve. There is a certain sense of community engendered by these meetings, which has been the most transforming feature of the program.

The Ambulatory Long Block not only has been fun, it’s been life-changing for me and many of the faculty. Those of us who have been engaged in this for the past six years have found so much joy in this work. It was hard at first, but it’s gotten better and it’s good to see something working well. We are very proud of the recognition we have gained through the Innovations Challenge.

—Eric Warm, M.D., is the program director of the University of Cincinnati Internal Medicine Residency Program and an Internal Medicine professor at the University of Cincinnati Academic Health Center. He accepted the AAMC Innovations Challenge Award for the Ambulatory Long Block on behalf of his institution. He can be reached at warmej@ucmail.uc.edu.

AAMC wants to hear about your programs that transform health care delivery! Submissions for the 2012 Innovation Challenge are due Friday, September 7, 2012, and are sought in these areas:

• Innovative initiatives that serve the chronically ill;
• Coordinated primary care delivery systems;
• Redesign of care for specific medicalconditions;
• Innovations in graduate medical education training.

 Three institutional winners will be announced at the AAMC Annual Meeting in November and awarded $5,000 each. Questions? Email innovationchallenge@aamc.org.