X + Y Scheduling Models for Internal Medicine Residency Programs-A Look Back and a Look Forward.

Many have called for a redesign of internal medicine training.1–,7 One result of this is that residency program directors have questioned the utility of traditional scheduling models with a weekly continuity clinic that conflicts with residents' inpatient rotations and duties. In fact, the Residency Review Committee for Internal Medicine has now mandated that programs “must develop models and schedules for ambulatory training that minimize conflicting inpatient and outpatient responsibilities.”8 Residency programs with large ambulatory training components (eg, primary care, internal medicine, family medicine) have traditionally allowed for such focused practice in ambulatory settings. Numerous internal medicine residency programs have adopted scheduling models that alternate blocks of traditional inpatient rotations with dedicated ambulatory blocks. The first report of such a model was a “4 + 1” model.9 Since then, dozens of programs have used variations on this theme, including 3 + 1, 4 + 2, and 6 + 2 models, and hybrids thereof.10,11 Given the number of variations, we refer to such schema as “X + Y” models, where “X” refers to the inpatient rotations, and “Y” refers to designated ambulatory blocks. All of the authors have extensive experience in crafting these schedules. Two of the authors (M.S. and S.Y.) have developed such schedules for more than a dozen internal medicine programs and a pediatrics program. These schedules, and the programs that use them, have several common themes. In addition, internal medicine and pediatrics residencies appear to have considerable overlap in educational issues and priorities.12 Given the growing interest in X + Y models, we thought it important to share some of our insights to help residency programs that are planning to restructure their educational curricula in this manner.