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Core Internal Medicine Training: Evolving beyond
the Clinical Teaching Unit
Mohamed Panju MSc MD FRCPC, Leslie Martin MD FRCPC MHPE, Lori Whitehead MD FRCPC
About the Author
Mohamed Panju MSc MD FRCPC, Associate Professor of Medicine at McMaster University, Hamilton, Ontario.
Leslie Martin MD FRCPC MHPE, Assistant Professor, Department of Medicine at McMaster University, Hamilton, Ontario.
Lori Whitehead MD FRCPC, Professor of Medicine at McMaster University, Hamilton, Ontario.
Corresponding author: mohamed.panju@medportal.ca
Submitted: April 28, 2019. Accepted: September 26, 2019. Published: February 28, 2020. DOI: 10.22374/cjgim.v15i1.367
Abstract
Over the past 50 years, the CTU has remained a core part of training for residents within internal
medicine training programs. At the same time, the needs of society have changed significantly
over the years, and current training needs to reflect this change. This is not a novel idea, but
one that we feel requires greater attention to adequately address the needs of academic teaching
hospitals across the country.
Resume
Au cours des 50 dernières années, la CTU est restée un élément essentiel de la formation des
résidents dans le cadre des programmes de formation en médecine interne. Dans le même temps,
les besoins de la société ont considérablement évolué au fil des ans, et la formation actuelle doit
refléter ce changement. Il ne sagit pas d’une idée nouvelle, mais d’une idée qui, selon nous,
nécessite une plus grande attention afin de répondre adéquatement aux besoins des hôpitaux
universitaires denseignement à travers le pays.
The concept of training students at the bedside is often attributed
to the leadership of Dr. William Osler in the late 1800s at
Johns
Hopkins University.
1
By the 1960s the Association of
Canadian
Medical Colleges provided further definition to
the concept
of training students at the bedside by developing
the Clinical
Teaching Unit (CTU).
2
CTUs were defined as
clinical areas
where education was provided by
undergraduate and graduate
medical trainees through the
care of patients, with graded levels
of responsibility depending
on their level of training.
3
In this
model, the supervising
physician is jointly appointed by both the
hospital and the
affiliated university.
3
At McMaster University, the main care
providers for patients on the CTU across three
teaching
hospitals are the PGY-1 residents and medical students
who report to the senior PGY-2 and PGY-3 residents. The
junior learners on the team gain experience in direct patient
care, including patient assessments, physical examination, and
documentation. The senior members of the team develop
leadership, teaching and consultancy skills. The role of direct
patient care for senior learners is de-emphasized in this model.
Over the past 50 years, the CTU has remained a core part
of training for residents within internal medicine training
programs. At the same time, the needs of society have changed
significantly over the years, and current training needs to reflect
this change. This is not a novel idea, but one that we feel requires
greater attention to adequately address the needs of academic
teaching hospitals across the country.
Canadian Journal of General Internal Medicine
8 Volume 15, Issue 1, 2020
Teaching and Learning
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Gap Analysis
At McMaster University, and many academic institutions across
the country, hospitals rely upon the CTU structure to provide the
majority of inpatient acute care to hospitalized patients through
geographic full-time (GFT) faculty, resident trainees and medical
students.
2
The number of residents in internal medicine has
climbed over the past ten years (from 336 to 437).
4
However,
patient volumes admitted to internal medicine have also been
climbing: in one study there was an increase by 32.4% between
2010 and 2015.
5
With climbing pressures to provide clinical service
to growing numbers of patients at academic institutions, it is
becoming an ever-greater to challenge to balance the educational
needs of trainees on the CTU. In 1993 a similar call was made
by Maudsley et al. to critically look at our health care patterns
and revise our conventional CTU training model.
Furthermore, as noted above, the majority of the CTU
environments are connected to Universities. These institutions
are often in large urban areas and part of tertiary care centres.
This limits the internal medicine trainee from reliably accessing
rural experiences. It is recognized that working within a rural
practice provides contextual learning, which has an important
influence on the development of relevant knowledge, skills and
attitudes for trainees, and future career choices.
6
The CTU model is heavily focused on medical inpatients.
Over the years, several medical conditions, which were previously
managed in the inpatient setting, are redirected to the ambulatory
setting. Also, there is now a movement towards rapid assessment
clinics for internal medicine where patients are seen from the
Emergency Department within 48–72 hours and there is timely
access to investigations. There is a societal economic benefit
to managing patients in the outpatient setting when possible.
Current trainees will need to develop the skills to manage patients
in the ambulatory care setting.
7
The traditional CTU is still an important part of core internal
medicine training, however, novel changes are required for training
programs to deal with some of the challenges listed above. As
noted, this is not a new issue facing medical educators in 2019.
This has been highlighted in prior literature dating back to 1986.
8
Many programs across the country have made changes to their
internal medicine training programs in an attempt to deal with
the above-highlighted issues. Similarly, additional rotations have
been built into the core internal medicine program at McMaster
University to address the need for a more diverse experience
and to help our trainees develop the competencies that will be
required of internists in today’s clinical environment.
The Royal College of Physicians and Surgeons of Canada
is leading all postgraduate training programs to transition
to a competency-based medical education system entitled
Competence by Design (CBD) by 2022.
9
CBD places significant
emphasis on the training context and the educational experiences
trainees encounter during residency. This has provided an even
greater incentive for program directors to reassess educational
programming.
At McMaster University, we have modified our curriculum
in several ways to meet the changing needs of our learners
and society (Table 1). These will be described in detail below,
however, to summarize we incorporated a formal Ambulatory
CTU (A-CTU) to emphasize the outpatient management of
medical patients. To balance teaching and patient care throughout
the day, and to ensure an opportunity for direct supervision of
residents during the primary assessment of new patients in the
Emergency Department, we created a medical service dedicated
to admitting Internal Medicine patients during the daytime.
A social medicine rotation was developed to provide learners
with the knowledge and skills required to care for vulnerable
populations, which is not consistently captured while working on
the CTU. Finally, we have incorporated a simulation curriculum
to address limitations in receiving direct observation and feedback
for certain clinical activities during the traditional curriculum.
Our modifications at McMaster University have helped to deal
with some gaps in the traditional CTU training, however, we
recognize that there are no perfect solutions. This article is to
serve as a platform for idea sharing between internal medicine
programs across the country.
Ambulatory CTU
We have developed an Ambulatory CTU (A-CTU) located in the
Boris Clinic at McMaster University, which has a similar graded
structure of the traditional CTU in an ambulatory setting.
10
In
this clinical environment, medical learners manage a variety
Table 1. Evolving Rotations
Activity PGY 1 PGY 2 PGY 3
Traditional CTU 12 weeks 14 weeks 4 weeks*
A-CTU 4 weeks 2 weeks
Preceptor Based Internal
Medicine Team
2 weeks
ER consultation and
Follow-up team
4 weeks 4 weeks
Social Medicine Rotation 2-4 weeks*
*elective
** simulation curriculum is longitudinal throughout noon rounds while on the clinical teaching
unit and academic half day.
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of complex medical patients in an outpatient setting referred
from the Emergency Department or community care providers.
The A-CTU provides a different learning experience than a
traditional outpatient clinic for several reasons. To begin, this
clinic provides an opportunity for PGY3 learners to practice
higher-level skills required for an academic clinician working in
an outpatient practice. This includes supervising and reviewing
cases with multiple learners or physician extenders (physician
assistant or nurse practitioner) in the outpatient setting, triaging
referrals, and following up on critical results. Similar to the
traditional CTU, there is also a full allied health team present
in the A-CTU, including a pharmacist, occupational therapist,
and social worker. Residents learn how to collaborate with
these providers in the ambulatory setting. There is a formal
academic curriculum on the A-CTU. This includes a dedicated
physical examination curriculum guided by PGY3 residents for
the PGY1 residents and an afternoon report where interesting
or challenging outpatient cases are discussed with all levels of
learners. Furthermore, the A-CTU provides an opportunity to
seek consultation from sub-specialty services sharing the clinic
space. The Boris clinic often has General Internal Medicine,
Diabetes, Dermatology, Thrombosis, Hematology, Obstetrical
Medicine, Rheumatology, Respirology and Infectious Disease
clinics running concurrently. If a sub-specialty opinion would
be of value, the PGY1 resident can seek formal or informal
consultation from the relevant specialist. This is both encouraged
and welcomed within the culture of the A-CTU. Also, there is
access to an ultrasound machine and procedural equipment.
Thus, similar to the CTU, learners can gain procedural or point-
of-care ultrasound skills while on the A-CTU.
Preceptor-Based Senior Medical Resident Role
In addition to functioning as a senior resident on a traditional
CTU, our senior residents complete a preceptor based inpatient
internal medicine rotation where they work under the direct
supervision of an attending physician. The one-on-one teaching
experience between faculty and senior learner sets the stage for
meeting targeted learning objectives and graded responsibility. We
anticipate that many of our graduates will work in community-
based hospital environments without formal CTUs, thus felt it
was important to develop the skills to function as an independent
practitioner. In the preceptor-based rotation, the senior resident
is responsible for independently managing inpatients. The
resident will complete all necessary clinical procedures. They
are responsible for reviewing the initial consultation with the
overnight admitting team, as well as bedside management
and discharge planning. This rotation also allows for direct
observation and feedback for the learner, which is important
in our current CBD curriculum.
Consultation and Follow-Up Medical Team
The traditional CTU usually manages patients admitted overnight
by
the on-call team. We have found it to be a challenge to both
education and clinical service for these teams to see new consults
during the day. For this reason, a new hybrid daytime consultation
team was developed. This team consists of a senior resident
and
1–2 junior learners who admit new consultations from the
Emergency department during daytime hours. The majority of
patients admitted by this team are followed until discharge. To
ensure this team can provide excellent clinical care and meet its
educational mandate, the number of patients is capped at 15–17.
Additional patients are then transferred to other clinical teams.
By
admitting new patients in the daytime, the learners have the
opportunity to receive direct observation and feedback from
the
supervising attending. In addition to commenting on the
history
and physical examination skills, the resident will have the
opportunity to receive feedback on management and resource
utilization at the time of admission. This is often missed when
reviewing a large number of patients in the morning. Also, by
having active inpatients and admitting new patients, the learner
will
learn how to manage time and priorities during the day.
In
addition to improved education, this rotation has helped to ensure
that daytime consults are seen promptly.
Social Medicine Rotation
We have identified that the CTU environment does not
consistently provide trainees with the skills or knowledge
required to provide optimal care to vulnerable patients, many
of
which have unique healthcare needs both in hospital and the
community. This rotation was designed to provide a breadth
of
community and hospital-based learning experiences to
familiarize trainees with at-risk populations (for example
newcomers, inner-city populations and patients with chronic
illness and disability, mental health or substance abuse
disorder
), the social determinants of
health and available
resources.
Our medical learners are provided an elective opportunity (for
either two or four weeks) to be part of this clinical service.
During
this rotation, the learner is paired with a faculty supervisor
who
provides an individualized orientation regarding expectations
and an
introduction to social medicine. The same supervisor
will debrief
with the learner weekly, review personal reflections
and compile
their assessments. The rotation is comprised of a combination of
core and elective half-day experiences, which include (but are not
limited to): inpatient addictions medicine, home visits with an
internist caring for vulnerable populations,
outpatient addictions
medicine clinics, shelter health clinic,
tuberculosis clinic, refugee
health clinic, aboriginal health clinic,
pre-exposure prophylaxis
clinic, needle exchange programs,
shadowing addictions workers
or social workers.
10 V o l u m e 1 5 , I s s u e 1 , 2 0 2 0 C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e
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Integration of Simulation
In addition to direct patient care on clinical CTUs, we have
integrated simulation as a core component of the clinical
experience and it takes place longitudinally over the three years
of core internal medicine training. It is a challenge to ensure
that each learner has direct observation and feedback of all
necessary clinical activities. The simulation curriculum has
been designed to address these gaps. During CTU teaching
sessions the residents are exposed to high fidelity acute care
experiences where they are observed and coached in their
medical knowledge and communication skills. This allows
for a formal debrief session, which can be difficult to arrange
during real acute medical situations. Also, technology for
simulation-based training has improved significantly over
the years such that realistic scenarios can be developed. Our
simulation curriculum includes specific half-day sessions where
procedures are taught and observed using partial task-trainers.
We have utilized simulated patients to help with communication
skills. Finally, we use simulation to provide further instruction
on the physical exam technique in the cardio-respiratory
system. Overall our simulation training has complimented
our clinical training.
Adapting Our Educational Training in Context
of Increasing Patient Care Volumes
At McMaster University, we are working to address the growing
patient volume requiring admission to internal medicine through
alternative care pathways from the traditional CTU. Each hospital
in our University Network is addressing this slightly differently,
however, thus far solutions have included the institution of a
hospitalist model and development of physician-based non-
traditional CTU teams supported by nurse practitioners or
physician assistants. We are aware that increased volumes can
affect resident education
11
but at the same time we want to ensure
that our residents are not shielded from these realities, as they
will need to be prepared for independent practice. Our learners
work collaboratively with each of the teams and participate
on the non-traditional CTU teams as part of their training.
Discussions are underway to remodel the CTU, such that it is
limited to a strict number of patients and certain geographic
areas of the hospital. This is being done for patient safety and
to provide an environment where learners have an opportunity
to maximize their learning.
Summary
The traditional CTU is important for core education in internal
medicine, but as the needs of society continue to shift, a more
diverse educational curriculum is important to meet the competency
requirements for internal medicine residents. CBD has forced
us to look closer at our training process and ensure that we are
providing the appropriate breadth and depth of experience within
internal medicine and attending to both the education and service
demands of our academic hospitals. Over the years, we have been
working to modify the internal medicine program at McMaster
University to reflect the requirements our learners will need for
future practice and to address gaps in the traditional CTU model.
We recognize that there are many potential solutions, and anticipate
that internal medicine programs across the country are similarly
responding with a variety of solutions. We hope that this article will
stimulate a conversation about how we can continue to rethink and
modify training programs with a shared goal of meeting shifting
societal needs, growing patient volumes and complexity, and new
educational and curricular requirements in the era of CBD.
References
1. Golden RL, William Osler at 150: an overview of a life. JAMA
1999;282(23):2252–8.
2. Maudsley RF, The clinical teaching unit in transition. CMAJ 1993;
148(9):1564–6.
3. Evans JR, Chute AL and Morley TP. The clinical teaching unit as an effective
organization for the education of residents under changing medical socio-
economic circumstances. I. Objectives and organization of the clinical
teaching unit: a white paper. Can Med Assoc J 1966;95(14):720–7.
4. Canadian Resident Matching Service. R-1 match interactive
data. 2018; Available at: https://www.carms.ca/data-reports/
r1-data-reports/r-1-match-interactive-data/.
5. Verma AA, Guo Y, Kwan JL, et al. Patient characteristics, resource use
and outcomes associated with general internal medicine hospital care: the
General Medicine Inpatient Initiative (GEMINI) retrospective cohort study.
CMAJ Open 2017;5(4):E842–e849.
6. Curran V. and Rourke J. The role of medical education in the recruitment and
retention of rural physicians. Med Teach 2004;26(3):265–72.
7. Dent JA. AMEE Guide No 26: clinical teaching in ambulatory care settings:
making the most of learning opportunities with outpatients. Med Teach
2005;27(4):302–15.
8. Schroeder SA, Showstack JA, and Gerbert B. Residency training in internal
medicine: time for a change? Ann Intern Med 1986;104(4):554–61.
9. RCPSC. Competence by Design: Reshaping Canadian Medical Education,
J.R. Frank and K.A. Harris, Editors; 2014.
10. Panju M, Kara A, Panju A, Fulford M, O’Bryne P, Haider S. An ambulatory
clinical teaching unit: filling the outpatient gap in internal medicine
residency training. Can J Int Med 2016;11(3):27–31
11. Wiese A, Kilty C, Bennett D. Supervised workplace learning in postgraduate
training: a realist synthesis. Med Educ 2018;52:951–69.
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