Evaluation of a longitudinal subspecialty clinic for internal medicine residents

Figures & data

Table 1. Respondent Characteristics

Characteristic	N (%)
Residents (N = 93)
Current residents	48 (51.6)
PGY2	28 (58.3)
PGY3	20 (41.7)
Alumni	45 (48.4)
Fellow	35 (77.8)
Attending	10 (22.2)
Preceptors (N = 15)
Faculty rank
Clinical instructor	1 (6.7)
Assistant professor	2 (13.3)
Associate professor	8 (53.3)
Professor	4 (26.7)
Years of experience as LSC preceptor	4.47 ± 4.75^a
Number of residents precepted^b	2.50 ± 1.12^a

Data are shown as the number (%) of respondents unless otherwise indicated.

Abbreviations: PGY2, second-year resident; PGY3, third-year resident; LSC, Longitudinal Subspecialty Clinic; SD, standard deviation.

^aData shown as mean ± SD.

^bData shown is for the academic year at the time of our study (2018–2019).

Figure 1. The distribution of specialty area is shown for residents (subspecialty of their LSC), alumni (current field of practice), and preceptors (subspecialty)

Figure 2. The distributions of resident and preceptor responses to Likert items for (a) overall satisfaction, (b) overall educational value, (c) effectiveness, and (d) curriculum and workflow. Bars to the right of the vertical baseline (0% axis) show the percentage of residents or preceptors who answered category 4 (green) or 5 (blue); bars to the left show the percentage who answered category 1 (red), 2 (orange), or 3 (yellow). The P values shown are for comparing the percentage of residents who answered category 4 or 5 with the corresponding percentage of preceptors. The pound sign (#) indicates an item posed only to alumni

TABLE 2. Results from Content Analysis of Responses to Open-Ended Items

Theme	Representative Quotes
Strengths
Career exploration in subspecialty of interest	Resident: “I was interested in pursuing ID as a career and thought that a subspecialty clinic would be good exposure to the field.” Preceptor: “Cultivating interest through increased exposure and expertise.”
Exposure to outpatient subspecialty practice	Resident: “I was able to explore what outpatient cardiology looks like and gain perspective on the full spectrum of cardiac care.” Resident: “It was one of the most useful experiences during residency and was actually very helpful in preparing me for fellowship. It allowed a much smoother transition when I had my own busy clinic in fellowship to have had this unique experience.” Preceptor: “Rheumatology has a very large outpatient component (majority of rheumatology occurs in the clinic) and the LSC gives a resident a real glimpse of the patients we care for.”
Facilitation of subspecialty career choice (confirmation of interest, ruling out a subspecialty)	Resident: “It confirmed my clinical interest in pulmonary medicine.” Resident: “Realized that GI fellowship was not the best fit for me and decided on cardiology instead.” Resident: “I really appreciated the flexibility with changing my LSC in my second year after I switched my choice of specialties.”
Access to longitudinal subspecialty mentorship (faculty, fellows, research opportunities)	Resident: “It provided the opportunity for me to develop a great mentorship relationship with my clinic preceptor which I found helpful in applying into the subspecialty.” Resident: “Helped me meet and form relationships with fellows.” Resident: “Helped me access mentorship and research projects in cardiology.” Preceptor: “Felt like I could really invest in [residents] as learners, teach a lot of topics over time, show them an ‘approach’ to thinking about our diseases that plays out over months, rather than just teaching digestible topic-based items. And most of all, chance to form an academic bond and relationship was great, and talk to them over the course of months about our field, careers, life, etc., was excellent.”
Obtaining LOR for fellowship	Resident: “The only good way to get LORs from clinical subspecialists at [our institution]. This is essential to the fellowship application process, as our elective rotations in inpatient subspecialties do not give you the same exposure and would be very stressful if needed as a source of LORs.” Preceptor: “This year I will be writing three letters of recommendation for fellowship.”
Value in residents seeing patients from their preceptor’s panel unfiltered	Resident: “It worked great just having me see people as they came in. I was expected to keep up with the pace of the fellows and share the work in the clinic. I really enjoyed being treated as a member of the team, not being specifically scheduled for certain ‘resident-level’ patients.” Preceptor: “There is also a value in seeing the unfiltered bell curve of all patients presenting to clinic.”
More well-rounded training for residents planning generalist careers	Resident: “I’m interested in learning more about oncology, and though I’ll be a generalist I think many of the concepts are applicable.” Resident: “My LSC helped me to understand my love for ID within general medicine. Throughout the experience, I was constantly thinking of how I would apply the knowledge I obtained in clinic to my primary care practice. It helped me to see that I was already envisioning myself as a primary care physician with a focused interest in ID.”
Areas for improvement
Desire for a structured, resident-level curriculum across the LSCs	Resident: “[The ideal LSC curriculum includes] online videos/modules for core topics (to allow consistency regardless of clinic).” Resident: “The sessions I attended were often targeted to the fellows and slightly above my knowledge level.” Preceptor: “[An area for improvement is] clear goals/objectives provided in advance from the medicine residency so that the experience is more uniform across different clinics.”
Preference for residents to see patients either from their own panel or from their preceptor’s panel filtered	Resident: “It would be nice to know further in advance who I would be seeing to be able to prepare more efficiently, and having patients on my schedule would be very convenient.” Resident: “I think seeing patients off the attending’s schedule allows for flexibility. If attendings are encouraged to set aside high yield patients, that could be helpful in ensuring a positive experience.” Preceptor: “[The ideal LSC workflow is for residents to] have their own small panel that they follow longitudinally.” Preceptor: “We try to filter patients for highest educational value to residents.”
Scheduling issues	Resident: “It’s challenging to skip in and out of the clinic as much as we do already because of vacation.” Resident: “I already have a decreased number of sessions due to vacations, 3-day weekends (my LSC falls on Monday).” Preceptor: “Keeping up with the schedules can be challenging – I’ve had days where I’ve been surprised to have a resident.” Preceptor: “[An area for improvement is] a more consistent resident presence. It’s too unpredictable to want to invest significantly.”

Abbreviations: GI, gastroenterology; ID, infectious diseases; LOR, letter of recommendation; LSC, Longitudinal Subspecialty Clinic.

Figure 3. The impact of having an LSC resident on preceptor efficiency in clinic, with data shown as the distribution of preceptor responses