Improving Ambulatory Training in Internal Medicine: X + Y (or Why Not?).

The Accreditation Council for Graduate Medical Education (ACGME) requirement that internal medicine residents spend one-third of their training in an ambulatory setting has resulted in programmatic innovation across the country. The traditional weekly half-day clinic model has lost ground to the block or "X + Y" clinic model, which has gained in popularity for many reasons. Several disadvantages of the block model have been reported, however, and residency programs are caught between the threat of old and new challenges. We offer the perspectives of three large residency programs (University of Washington, Emory University, and Massachusetts General Hospital) that have successfully navigated scheduling challenges in our individual settings without implementing the block model. By sharing our innovative non-block models, we hope to demonstrate that programs can and should create the solution that fits their individual needs.