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Description of a combined internal medicine--pediatrics continuity clinic for combined program residents.


Background. We sought to examine the ambulatory experience in our medicine-pediatrics clinic.

Methods. Data on patient visits were abstracted from the hospital's clinic utilization summary and charge sheets. A survey assessed resident satisfaction.

Results. Residents saw 63% adult and 37% pediatric patients, with an average of 3.5 patients per clinic. There was no significant difference in the mean number of patients seen by residents when compared by postgraduate year. Half of all visits were coded for 2 or more diagnoses. Hypertension and diabetes were the most common adult diagnoses, and well-child care and asthma were the most common pediatric diagnoses. Residents were satisfied with the clinic.

Conclusions. The adult and pediatric patient visits were well balanced, with broad complexity. Residents rated their satisfaction with the clinic highly. Our experience may provide valuable information to programs that have a med-peds clinic or are considering creating one.

RESIDENCY TRAINING in combined internal medicine and pediatrics (med-peds) is emerging as an important source of primary care physicians. (1-3) A survey of graduates of med-peds training programs found that 80% of recent medpeds graduates are practicing generalists who care for adults and children. (2) Assuring that residents are adequately trained to practice in an ambulatory setting has become a priority in both internal medicine and pediatrics. (4,5) One important source of experience in ambulatory training for residents is the weekly or in some instances twice weekly continuity of care clinic, where residents see patients with diagnoses similar to those they will see in practice after residency. (6) Thus, it is vital that residents training in internal medicine, pediatrics, med-peds, and family practice have substantial and consistent training in ambulatory settings such as their continuity clinics.7 The Guidelines for Combined Training in Internal Medicine and Pediatrics state that whenever it is feasibl e, joint medpeds experiences should be encouraged. (8)

Forty-six percent of med-peds programs report that they have combined internal medicine! pediatric continuity clinics (D. S. Miner, MD, Written Communication, November, 1999). This combined experience provides an opportunity for residents to care for families in one clinical setting, similar to how they will likely practice after residency, while working closely with other med-peds residents and faculty. Many studies have examined the content and quality of the ambulatory training in continuity clinics in internal medicine, pediatric, and family practice training programs. (19-14) We believe this is the first systematic analysis of a combined internal medicine/pediatrics continuity clinic. We describe our experience with a recently created combined med-peds resident continuity clinic in a large university hospital setting, detailing specifically our patients' demographics, the relative percentage of adult and pediatric patients, the number of patients and complexity of cases seen by residents, and the residen ts' satisfaction with the experience.


The combined internal med-peds resident continuity clinic studied has been in existence for 18 months. It is located at a university-based, state-operated hospital in a medium-sized metropolitan area. Patients seen by a resident in the first year of training with alternating internal medicine and pediatric continuity clinics are transferred to the resident's care in the combined med-peds clinic in the second year.

We retrospectively collected data from December 1998 through April 1999 from our med-peds clinic. Data were drawn from the Medical Center of Louisiana at New Orleans Ambulatory Clinics Utilization Report. This monthly summary indicates the number of clinic visits, number of residents attending clinic, and number of new and return clinic visits. Data contained in this report were collected and reported after each clinic by the clinic nursing and office staff.

The charge sheets filled out by the resident at each clinic visit identify the number of diagnoses and the resident's postgraduate year. A list of 20 of the most common adult and pediatric diagnoses, identified by ICD-9, was used to record the frequency of diagnoses.

Resident satisfaction with the clinic was obtained from a survey including 10 questions on a 5-point Likert scale. Questions were constructed to assess residents' satisfaction in 4 areas: (1) educational experience, (2) adequacy of staff supervision, (3) the distribution of adult and pediatric patients and degree of continuity, and (4) the quality of ancillary staff and services. Overall satisfaction was taken from the mean Likert score, and a mean Likert score was calculated for each of the four areas.


Patient demographic data are reported in Table 1. Table 2 shows the average number of patients seen per resident per clinic and the number of diagnoses per visit. There was no significant difference in the average number of patients seen by residents of different postgraduate years (P = .16). Frequency of common diagnoses is shown in Table 3. All 14 residents completed the anonymous satisfaction survey, with the overall result that residents were highly satisfied with the combined continuity clinic experience (mean Likert value = 4.1). Residents were most satisfied with the educational experience (mean Likert value = 4.4) and highly satisfied with the staff supervision (mean Likert value = 4.2) and the patient distribution and continuity (mean Likert value = 4.0). Residents rated their satisfaction with the quality of ancillary services the lowest (mean Likert value = 3.7).


Development of a med-peds clinic in residency training programs has occurred nationally, as the med-peds training guidelines encourage the institution of combined continuity clinics (8) Justifying the creation of a clinic requiring space, staff, and preceptors able to meet the needs of all age groups can be difficult. Also, some faculty in training programs may argue that removing the med-pea resident from mainstream intensive training could jeopardize their training by decreasing their exposure to medicine and pediatric faculty.

Residents in our program saw 20% more adult patients than pediatric patients. Although in ideal circumstances, there would be an equal number of adult and pediatric patients, it is not surprising that the numbers were not equal. The most recent National Hospital Ambulatory Medical Care Survey (NHAMCS) found that approximately 34% of outpatient department visits were by patients aged <24 years. (15) Thus, some inequality in the relative proportion of adult and pediatric patients may well be expected after residents complete their training and move into practice. We have found no other data on the percentages of adult and pediatric patients seen in clinics that are similar to ours.

The average of 3.5 patients per resident per clinic day, though less than desirable, is comparable to other averages previously reported for either internal medicine or pediatric residency continuity of care clinics. One recent survey of pediatric residency program directors reported that first-year residents saw 4 patients per clinic visit on the average, while upper level residents saw an average of 5 patients. (4) However, these averages were based on estimation by program directors rather than by actual numbers. Our estimation before this study would have been similar to the findings of that survey. A recent comparison conducted in a large pediatric residency program of a newly begun community outpatient practice experience with the program's existing hospital-based continuity found that the residents in the traditional setting averaged only 1.7 patients per clinic, compared with 6.2 patients in the new, practice-based setting. (12) However, the majority of cases in this study were acute and not follow-u p visits. (13) Our clinic does not regularly see acute visits.

Several other factors may also help explain the low average. These factors include poor compliance with scheduled follow-up visits, long patient waiting times, a hand written scheduling system with single mailed clinic reminders, and the relative newness of our clinic. Because of our findings, we have successfully taken steps to increase the number of patients visiting our clinic. We have instituted a computerized scheduling system, increased the number of newborn and emergency room follow-up appointments, and made a wider range of time slots available for appointments to decrease waiting time.

The five most common diagnoses in the NHAMCS were routine infant or child health check, normal pregnancy, essential hypertension, diabetes, and upper respiratory tract infection. (15) In our study, the vast majority of patients were seen in follow-up, with only 10% seen as new visits. This high percentage of return visits is comparable to the findings of 81% return and 16% new visits in the NHAMCS. (15) Also, while in training our residents encounter throughout their rotations a predominance of "new" patients, and the continuity of care clinic is extremely valuable in allowing residents a unique opportunity to learn about both developmental stages and the progression of illness over time.

Half of the patients had two or more diagnoses, while 21% of patients overall had three or more diagnoses. We believe this implies that residents see an appropriate number of complex problems in their continuity of care clinic. Diagnoses representing an acute problem, such as an upper respiratory tract infection, are less frequent in our sample, likely because our clinic is available only on two afternoons a week.

Overall, residents were satisfied with their experience in the med-peds clinic, but these data must treated cautiously since we did not have a comparison group. Residents rated their satisfaction with the educational experience most highly. They were highly satisfied with the patient distribution and the staff supervision, and least satisfied with the quality of ancillary staff and services. One satisfaction survey of internal medicine residents found similar results, with residents rating their educational experience in continuity clinic highest and the ancillary services provided by nonmedical staff the lowest (10) An older survey of internal medicine residents showed that residents assigned a low ranking to their educational experience in continuity clinic. (16) One explanation for the difference in residents' satisfaction with educational experience may be partly explained by another study's finding that continuity of care was highly correlated with resident and faculty satisfaction with the outpatient e xperience. (17)

In conclusion, we describe our experience with a med-peds continuity of care clinic in a large, university hospital training program. As the number of med-peds graduates continues to increase, assuring that med-peds residents are well trained to perform in primary care ambulatory settings is vital. Combined med-peds clinics offer unique opportunities for resident training in a supportive setting with a patient population that is likely similar to future practice. We hope that our experience will help both those programs that already have a combined med-peds continuity clinic and those considering one.


(1.) Ciccarelli M: The philosophy of medicine-pediatrics. Am J Med 1998; 104:330-331

(2.) Lannon C, Oliver T, Guerin R, et al: Internal medicine-pediatrics combined graduates: what are they doing now? results of a survey. Arch Pediatr Adolesc Med 1999; 153:823-828

(3.) Schubiner H, Lannon C, Manfred L: Current positions of graduates of internal medicine-pediatrics training programs. Arch Pediatr Adolesc Med 1997; 151:576-579

(4.) Dumont-Driscoll MC, Barbian LT, Pollock BH: Pediatric residents' continuity clinics: how are we really doing? Pediatrics 1995; 96:616-621

(5.) Charney E: The education of pediatricians for primary care: the score after two years. Pediatrics 1995; 95:270-272

(6.) Papadakis MA: Categorical medicine residents' experiential curriculum. Am J Med 1995; 98:7-12

(7.) Schatz IJ: Family practice, internal medicine, and pediatrics as partners in the education of generalists. Acad Med 1996; 71:35-39

(8.) Guidelines for Combined Internal Medicine/Pediatrics Residency Training. American Board of Pediatrics; American Board of Internal Medicine, 1999

(9.) Ellsbury KE, Schneeweiss R, Montano DE, et al: Content of the model teaching unit ambulatory care training and continuity of care in six family practice residency programs. J Fam Pract 1987; 25:273-278

(10.) Swing SR, Vasilias J: Internal medicine residency education in ambulatory settings. Acad Med 1997; 72:988-996

(11.) Kosecoff J, Fink A, Brook RH, et al: General medical care and the education of internists in university hospitals. an evaluation of the teaching hospital general medicine group practice program. Ann Intern Med 1985; 102:250-257

(12.) Recchia KC, Pteros TM, Spooner SA, et al: Implementation of the community outpatient practice experience in a large pediatric residency program. Pediatrics 1995; 96:90-98

(13.) Petrusa ER, Yunker R, Brink S: Evaluating continuity of care in primary care internal medicine programs. South Med J 1983; 76:786-789

(14.) Barratt MS, Tanz RR: A survey of the structure and function of pediatric continuity clinics. Am J Dis Child 1992; 146:937-940

(15.) McCaig LF: National Hospital Ambulatory Medical Care Survey: 1997. Outpatient Department Summary. Advance data from vital and health statistics, No. 307. Hyattsville, Md, National Center for Health Statistics, 1999

(16.) Brook RH, Fink A, Kosecoff J, et al: Educating physicians and treating patients in the ambulatory setting. where are we going and how will we know when we arrive? Ann Intern Med 1987; 107:392-398

(17.) Blankfield RP, Kelly RB, Alegmano SA, et al: Continuity of care in a family practice residency program. impact on physician satisfaction. J Fam Pract 1990; 3 1:69-73

Demographic Data on Patients Seen in a Medicine/Pediatrics Continuity
Clinic (December 1998 through April 1999)

Age (yrs)

 18-45 44 (14%)
 >45 164 (50%)

Total 208 (62%)


 <2 58 (18%)
 2 to 18 65 (20%)
Total 123 (37%)
Female 214 (64%)

Payor Mix

 Medicaid 67 (20%)
 Medicare 50 (15%)
 Free care 87 (26%)
 Other 127 (38%)

Clinic Visit Data (December 1998 through April 1999)

Total patients 955
Total clinics 39
Mean residents per clinic 7
Mean patients per resident per 3.5
Return visits 857 (90%)
Total patients billed 331 (35%)
Number of diagnoses per visit
 [greater than or equal to]3 71 (21%)
 2 101 (50%)
 1 159 (48%)

Diagnostic Frequencies of Patient Visits (December 1998 through April

Adult diagnoses

 Hypertension 146 (72%)
 Diabetes 68 (33%)
 Osteoarthritis 21 (10%)
 Congestive heart failure 20 (10%)
 High cholesterol 18 (9%)
 Chronic obstructive 16 (8%)
 pulmonary disease
 Thyroid disorders 14 (7%)
 Abdominal pain 9 (4.5%)
 Anemia 8 (4.5%)
 Depression 7 (3.5%)
 Coronary artery disease 6 (3%)
 Chest pain 5 (2.5%)
 Back pain 3 (1.5%)

Pediatric diagnoses

 Well child care 73 (58%)
 Asthma 23 (19%)
 Upper respiratory tract 5 (4%)
 Otitis media 4 (3%)
 Atopic dermatitis 4 (3%)
 Developmental delay 2 (2%)
 Failure to thrive 1 (1%)


* Residents reported high satisfaction with the combined continuity clinic experience.

* Residents were most satisfied with the educational experience.

* Justifying the creation of a clinic requiring space, staff, and preceptors able to meet the needs of all age groups can be difficult.

* Removing the med-peds resident from mainstream intensive training could jeopardize training by decreasing exposure to medicine and pediatric faculty.
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Article Details
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Author:Cummings, Terry L.
Publication:Southern Medical Journal
Article Type:Statistical Data Included
Geographic Code:1USA
Date:Dec 1, 2001
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