The Gift of Empanelment in a “Clinic First” Residency

The reflection article "The Gift of Empanelment in a 'Clinic First' Residency" (1) vividly illustrates the value of prioritizing continuity and the primary care experience during residency training. The traditional scheduling of residents in the primary care clinic for 1-2 half day sessions per week often leads to significant struggles in continuity for both patients and residents, access to care, and stable, effective team- based care. The oft-resulting chaos and dysfunction in the teaching clinic environment teaches residents during their formative training experience that a career in primary care will be frustrating and unsustainable (2).

Increasingly, family medicine residency programs are re-evaluating the traditional scheduling paradigm in efforts to transform their teaching clinics into high-functioning practices that achieve both excellent education and patient centered care. Faculty at Washington State's Valley Medical Center Family Practice Residency first coined the term "Clinic First" for a set of curricular and scheduling changes made to support continuity and outpatient clinic excellence in their teaching practice (3), and this has been since adapted to signify the philosophy of prioritizing the primary care clinic in residency training (4). Many programs are using the concept of "Clinic First" to reimagine resident scheduling in a variety of ways. These range from changing half-days of clinic into full days to allow better immersion of the learner into their clinical environment (rather than running from an inpatient service to clinic in the middle of the day), to complete overhauls of traditional rotations such as the model described here.

Departing from traditional scheduling models by using a thoughtful approach to prioritizing continuity can result in innovations that seem novel to training settings, yet better reflect for trainees the actual practice of primary care. For example, the longitudinal curriculum described in "The Gift of Empanelment in a 'Clinic First' Residency" turns the status quo of panel sizes and amount of time spent in clinic by resident year on its head. Rather than taking it as a given that interns have the least time in clinic and least number of patients per clinic session, and thus can only manage a small panel size, the approach is that of assuming residents should train by managing a full continuity panel from day one, and accordingly scheduling more clinic sessions in intern year than in second and third years. Approaching residency scheduling with a "Clinic First" philosophy can reveal many ways in which the teaching clinic experience can be invigorated by challenging traditional scheduling paradigms.

1) Sundar, KR. The gift of empanelment in a "Clinic First" residency. Ann Fam Med. 2018;16(6):563-565.

2) Keirns CC, Bosk CL. Perspective: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. 2008;83(5):498-502.

3) Neher JO, Kelsberg G, Oliveira D. Improving continuity by increasing clinic frequency in a residency setting. Fam Med. 2001;33(10):751-755.

4) Gupta R, Barnes K, Bodenheimer T. Clinic first: 6 actions to transform ambulatory residency training. J Grad Med Educ. 2016;8(4):500- 503.

Competing interests: None declared