Clinic First: 6 Actions to Transform Ambulatory Residency Training.

‘‘S o let me begin by stating what some may consider obvious, and others a heresy: patient-centered care and medical education—as currently practiced—cannot coexist,’’ a medical educator graphically wrote last year. Teaching clinics are often poorly organized, discouraging trainees from choosing primary care or outpatientbased careers. This perspective makes the case that resident teaching clinics can provide patient-centered care and excellent resident education, and that the 2 goals can be in harmony. Traditionally, most residents spend 1 to 2 half-days per week in clinic. This undermines the foundational principle of continuity for patients, staff, and learners. The priorities in training do not match those in the world beyond residency. In 2010, Americans made 600 million primary care visits compared with 35 million hospital admissions. Since the advent of the hospitalist, primary care physicians and some medical specialists spend little or no time providing inpatient care. Yet, in many residency programs, the hospital comes first and the clinic second. A research team from the Center for Excellence in Primary Care at the University of California, San Francisco, conducted site visits to 18 internal medicine, family medicine, and pediatric residency teaching clinics. We chose the sites using reputational sampling. Members of our research team asked 17 national experts in graduate medical education to name highly regarded teaching practices. The 17 experts were chosen from professional contacts we personally knew and from authors of publications on residency program issues. Site visits included interviews and observations using a structured site visit guide. Site visit reports were coded and analyzed through an iterative process to identify themes. Six common themes emerged, which we distilled into a model called ‘‘Clinic First’’ (BOX). The Clinic First model emphasizes that ambulatory training is a top priority, and creating high-performing teaching clinics is paramount. We found that programs embracing the Clinic First goal have implemented the following 6 actions.