Do you need good inpatient experience to be good at outpatient?

[GoodmanBrown]

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I was doing a "pre-clinical" rotation my school has us do in our second year. I was at a health clinic staffed by residents from a local, school-affliated FM program. The one resident was really positive about this particular residency because the FM program runs the entire hospital nearby (it's unopposed). He said that he chose the program because it's important to get good inpatient experience to be knowledgeable about outpatient work.

True or false?

 

[lowbudget]

Hmm... I think the premise that training in a 100% inpatient setting, dealing with sick, unstable patients would somehow magically make you competent in outpatient medicine is an oversimplification that's flawed and ignorant (in my humble opinion). I've heard this argument from residents at unopposed programs with great inpatient experience, who's outpatient clinics are a total mess. There are certain pathologies that you see in the inpatient setting and certain pathologies you see in the outpatient setting; and likewise, there are certain cases that should be managed inpatient, while others outpatient. The difference between family medicine and internal medicine by design (i.e. by RRC) is that family medicine has more outpatient experience and continuity than internal medicine residencies. That's by design.

That said, from a medical care standpoint, it's important to be skilled at BOTH inpatient and outpatient work because it makes you just that much more effective at managing a patient. Having those skills help you make better decisions when you're in the hospital and when you're in the outpatient setting.

What you should look for, in my humble opinion, is a BALANCED residency program, one that gives equal emphasis for both hospital and critical care work as well as outpatient and resource-limited settings. I feel like some university programs have given up on themselves when it comes to inpatient work. These programs don't teach residents how to manage a hospitalized patient without all the luxury and support of the resources around them and their program tries so hard to protect the residents that they end up handicapping them. I also feel that some unopposed community programs are so inpatient-heavy that residents graduate so narrowly trained and incapable of working in the setting where most family doctors work (the outpatient setting). I predict that over the next several years, the hospital will continue to be viewed as an expensive locale for care and that more and more patients will be forced to be taken care of in the outpatient basis. This means that more and more sick patients will need to be managed in the outpatient setting, where they used to be managed in the inpatient setting and it's our job to figure out who truly needs to be in the hospital, and who we can handle in the clinic. This is the stage that's set with bundled payments and ACO's.

There are many reasons why some unopposed programs are over-inpatient-heavy. One of those reasons is money. Government pays the hospital system for the amount of time residents physically spend in the hospital. Programs are required to report this number so that hospitals get paid.

From your standpoint, I encourage you to find a program that's balanced. Not too outpatient heavy, not too inpatient heavy; but busy enough in both where if you wanted to develop a particular interest/competency that it has room for you to do so. It's probably easier to find a program that's outpatient-strong in family medicine. I'm a fan of unopposed programs in family medicine but I caution you when you're looking at programs to pick what's right for you. For me, I think it's important to be balanced: strong in both inpatient and outpatient medicine.

 

[Shinken]

it's important to get good inpatient experience to be knowledgeable about outpatient work.

True or false?

True.

A good inpatient experience will make you a better clinician in an outpatient setting.

 

[RLMitchell1]

"Not too outpatient heavy, not too inpatient heavy;"

What would you consider a good balance? Ie how many afternoons per week in continuity clinic as PGY1, 2 and 3?

 

[montessori2md]

"Not too outpatient heavy, not too inpatient heavy;"

What would you consider a good balance? Ie how many afternoons per week in continuity clinic as PGY1, 2 and 3?

I don't think this is the right question. Part of this depends on what you want to get out of your own training. Are you thinking about hospitalist work? Then a schedule where you "live" in the hospital for some months and are 100% outpatient other months should be fine for you. Are you considering "old school" FM where you spend half your day in the hospital and half the day in clinic? Then you need to find a program that allows you to do that.

Some programs use PGY2s and 3s to supervise interns on service -that is, you are with them, inpatient, as part of the team. Others have you randomly showing up to teams on q10 (or greater) call to fill in gaps. You walk onto the team for one night to supervise. You aren't on that service, you don't know the patients, you're there for a Sat night and you make sure the interns are ok. There is a huge difference between those two experiences. Which do you want?

What do you actually do while inpatient? How many patients do you typically manage? What = "surgery" is wildly different from program to program. Are you managing patients? Doing colonoscopies? First assisting in the OR? What do you want?

Also, for clinic, some are totally EMR, very efficient, carefully organized into teams. Others are 100% paper charts or partial EMR. The working relationships with the attendings may be intimate, or they may basically turn you loose.

Then there are didactics. Is the focus on inpatient or outpatient, or balanced? What about research?

 

[lewstools]

There may come a time when there are no facilities, only your skills in the field. Consider physicians practicing in third world countries and the possibility that at some point in your career you may elect to render your skills abroad or in a disaster setting. In training, it serves you well to balance between inpatient and outpatient skills as well as honing abilities to work with what may be difficult waters to navigate. Be prepared for anything. Overly depending on technology is fine, but; being able to serve your patients without clean water and electricity? This will be a challenge. It's always compelling to learn from colleagues who have practiced in those sorts of environments.