Impact of 4 + 1 block scheduling on patient care continuity in resident clinic.

BACKGROUND: Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4 + 1 block scheduling is one innovative approach to enhance ambulatory education. AIM: To determine the impact of 4 + 1 scheduling on resident clinic continuity.
SETTING: Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4 + 1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective. PARTICIPANTS: First-year internal medicine residents. PROGRAM DESCRIPTION: We measured patient-provider visit continuity, phone triage encounter continuity, and lab follow-up continuity. PROGRAM EVALUATION: In traditional scheduling as opposed to 4 + 1 scheduling, patients saw their primary resident provider a greater percentage; 71.7% vs. 63.0% (p = 0.008). In the 4 + 1 model, residents saw their own patients a greater percentage; 52.1% vs. 37.1% (p = 0.0001). Residents addressed their own labs more often in 4 + 1 model; 90.7% vs. 75.6% (p = 0.001). There was no significant difference in handling of triage encounters; 42.3% vs. 35.8% (p = 0.12). DISCUSSION: 4 + 1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity.