The constant tension between time-limited outpatient visits and the need to spend time training future health care providers can result in rushed patient encounters and suboptimal learning for the trainee. However, the Ambulatory Diagnostic and Treatment Center (ADTC) Outpatient Clinic piloted at the VA Boston Healthcare System may be a possible solution.
Described in a paper in the journal Academic Medicine, the authors detail the 25-year experience of the ADTC whose unique emphasis on education amongst other rotations for the learner is reinforced by the selective enrollment of patients who simultaneously offer robust educational opportunities while receiving VIP-level evaluations. Patients who come through the ADTC clinic are apt to benefit when they have disorders that are unstable or rapidly evolving (such as unexplained weight loss, new lower extremity edema) but not sufficiently ill that they require inpatient hospitalization. The clinic offers rapid outpatient resolution of clinical issues via tightly spaced outpatient follow-up visits which typically cannot be offered or accomplished in busy primary care clinics. It also aims to reduce costs and readmissions by concentrating health care efforts on complex and tenuous patients who would not be able to be adequately served by busy time-limited primary care visits.
While offering care for patients for whom other services may not be suitable, available or expeditious, the ADTC simultaneously prioritizes education of trainees. It is a core rotation for Boston Medical Center medical residents and students from BUSM. Faculty triage patients by weighing factors such as urgency, educational value, complexity, and instability of diseases in conjunction with the resources, availability, and appropriateness of other services within the medical center.Trainees are given the opportunity to make complex diagnoses and consolidate knowledge related to commonly managed conditions. Additionally, the clinic fosters an environment conducive to concentrated literature review, time for reflection and clinician-as-educator training. According to the authors this rotation has consistently received positive feedback from residents and medical students as a valuable learning experience.
Via its outpatient “intensivist” model, ADTC clinicians focus their attention on signs and/or symptoms that busy providers may overlook or not be able to attend to within a reasonable amount of time. The ADTC is staffed by one attending physician, three internal medicine residents and a fourth-year medical student. In this model each new patient visit lasts 90 minutes or more, allowing for a complete history and physical exam and time to explore psychosocial issues. “Without this model, many of these patients may be admitted to the hospital for expedited work up, sometimes unnecessarily and contributing to cost or referred to many subspecialists,” explained corresponding author Richard Serrao, MD, assistant professor of medicine at Boston University School of Medicine (BUSM) and Medical Director of the ADTC.
“By providing a detailed description of the structure of this clinic, our aim is to disseminate a teaching/patient care model that other academic medical centers could profit from,” added co-author Jay.D. Orlander, MD, professor of medicine at BUSM and Associate Chief, Medical Service VA Boston Healthcare System.
The authors hope to promote this model as a solution to enhancing both the training of physicians and patient accessibility for which both the patient and trainee can benefit.