AIMGP and Ambulatory Education Renewal

1. AIMGP and Ambulatory Education Renewal July 2008 & onward

2. Vision A well-organized system of ambulatory educational experiences that fosters the development of strong skills in outpatient care, in which core trainees are mentored by expert clinicians in a variety of subspecialty settings, to a high degree of consultant expertise.

3. Background • AIMGP has been the only “programmed” element of ambulatory education in the core training program thus far • Not universally popular; recommended to be changed in the RC review • Survey of PGY1/2 trainees in 2006-2007 undertaken – principal results follow

4. Survey results – contribution of existing AIMGP

5. Positive Features • Longitudinal relationship between staff and residents, mentorship, collegial atmosphere • Opportunity to get practice and feedback on problem prioritization, communication, counselling, organization of care • Opportunity to follow up on own patients from hospital setting and learn about post-DC course

6. Negative Aspects • Site to site variability in clinic support, infrastructure, patient referral patterns • Stress among PGY2s of combining AIMGP with busy inpatient rotations • Lack of clarity of educational objectives, and role compared with primary care

7. A New Design • Principles: • The AIMGP structure alone should not be relied upon to develop residents’ competencies in ambulatory practice • PGY2 year is too crowded to add a longitudinal component that is sustainable • Subspecialty environments can be developed to refine expert level competencies in ambulatory care

8. Details – PGY1 Year (July 2008) • PGY1 trainees will come to their base hospital’s AIMGP office as they currently do • One half day per week – not post call or on ER • Will follow a combination of ER referrals, self-referrals from ward, and other MD referrals • Goals and objectives of the experience: based on mentoring the development of basic skills in ambulatory care

9. Details – PGY2 Year (July 2008) • No longitudinal ambulatory clinic in the PGY2 year – affects current PGY1 trainees • Trainees will still have outpatient experiences on some rotations as per usual • (eg. Respirology clinic while on Resp)

10. Details – PGY3 Year (July 2009) • This involves the current PGY1 cohort • 18 month timeline for development • Will have two 6-month longitudinal ambulatory experiences alongside regular rotations • Will attend on a half day per week basis • Will spend 6 months in a subspecialty setting (including possibly GIM), and then switch to another one • Model is a 1-on-1 trainee-mentor relationship, although this may vary by setting • Not simply transporting AIMGP into the PGY3 setting

11. PGY3 Year continued • Focus for this experience: the development of general senior-level consultant skills, and subpecialty knowledge • Subspecialties will be recruited based on: • Faculty interest • Ability to provide a longitudinal clinic experience • Participation in developing specific objectives and assessment methods

12. Choice of PGY3 experiences • Concept 1: Trainees choose from a number of options based upon need to “round out” their core experiences prior to fellowship • Concept 2: Trainees are allowed to choose based upon career plans – to ensure compatibility

13. PGY3 Educational Design • A set of generic objectives and evaluation methods will be developed to ensure trainees are gaining the desired competencies from the experience, in addition to subspecialty knowledge

14. Ramifications of the Change • Current PGY3 half-day will have to move – suggest the PGY2 year • This will affect the current PGY1 group • Will need to be enacted as of July 2008 • Major coordination effort for all trainees to have clinics assigned • Policies to be developed about clinic attendance and conflicts with rotations

15. Progress So Far • All current AIMGP settings have agreed to provide the PGY1 experience as outlined • Start date: July 2008 • Various internal impacts on clinic functioning will need accommodation • Departmental/program support will be necessary • Working group of AIMGP attendings will develop educational objectives and plan for implementation • Known issues at each site will be addressed

16. PGY3 Progress • Informal discussion with some subspecialty leaders so far • Variable response – some educational leaders enthusiastic about participating

17. Questions to Consider • Does this model improve upon the current situation? • Is this likely to improve residents’ satisfaction with ambulatory education? • What other ramifications might arise from this model? • Should we go ahead with implementation of the PGY1 AIMGP as outlined in July 2008?

18. Contacts • Dr. Ken Locke – klocke@mtsinai.on.ca • Dr. Katina Tzanetos – katina.tzanetos@uhn.on.ca • Dr. Stephen Hwang – hwangs@smh.toronto.on.ca • Dr. Kevin Imrie – kevin.imrie@utoronto.ca